LAI  ION 


OF   THE 


ERVICAL  SYMPATHETIC 


DE  SCKWEINITZ 

WILDER 

BALL 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 
Mrs.  Clifford  B.  Walker 


He Iat ton  of  tfye  (Ecrmcal 
Sympathetic  to  tfye  (Eye   ::   :: 

Papers  rcab  before  tfye  Section  on 
Ophthalmology  of  tfye  American 
IHebical  Association,  at  tfye  Annual 
Session,  Hero  Orleans,  TTtatj,  ItyQZ 


'The  Physiology  of  the  Sympathetic  in  Relation  to  the 
Eye." 

G.  E.  DE  SCHWEINITZ,  A.M.,  M.D..  Philadelphia. 

'The  Influence  of  Resection  of  the  Cervical  Sympathetic 
Ganglia  in  Glaucoma." 

WILLIAM    H.    WILDER,   M.D..    Chicago. 

'Influence  of  Resection  of  the  Cervical  Sympathetic  in 
Optic-Nerve  Atrophy.  Hydrophthalmos  and  Exoph- 
thalmic Goiter.'" 

JAMES   MOOEES    BALL,   M.D.,    St.    Louis. 

•Pathology  of  the  Cervical  Sympathetic." 

JOHN  E.  WEEKS,  M.D..  New  York. 


CHICAGO  : 

TRESS      OF     AMERICAN      MEDICAL     ASSOCIATION 
ONE    HUNDRED    AND    THREE    DEARBORN    AVENUE 
1904 


ttawdkgi 
Ubraij 


THE  PHYSIOLOGY  OP  THE  SYMPATHETIC 
RELATION  TO  THE  EYE. 


G.  E.  DE  SCHWEINITZ,  A.M.,  M.D. 

PHILADELPHIA. 


The  object  of  this  paper  is  to  present  a  resume  of  our 
knowledge  of  the  physiology  of  the  sympathetic  in  so  far 
as  it  relates  to  the  eye,  and  is  based  on  a  study  of  the 
extant  literature.  This  literature  has  assumed  large 
proportions,  and  it  must  be  evident  that  in  the  limited 
time  at  my  disposal  it  would  be  impossible  to  review  it 
elaborately.  The  endeavor,  therefore,  has  been  to  bring 
into  prominence  such  physiologic  problems,  and  the 
subjects  related  to  them,  and  to  a  minor  degree  some 
subjects  suggested  by  them,  which  are  of  particular  in- 
terest to  us  as  ophthalmic  surgeons. 

i.    INTRODUCTORY    REMARKS    ON    THE    ANATOMY    AND 

PHYSIOLOGY  OF  THE  SYMPATHETIC. 

To  introduce  the  subject  it  seems  proper  to  say  a 
word  or  two  in  regard  to  the  general  anatomy  and  phys- 
iology of  the  sympathetic.  Following  Professor  Thane's 
classification,1  which  has  also  been  adopted  and  elab- 
orated by  Onuf  and  Joseph  Collins,2  it  may  be  said 
that  the  sympathetic  nerve  is  composed  of  a  collection 
of  ganglia,  cords  and  plexuses,  or,  more  specifically,  of 
two  great  gangliated  cords,  intermediate  and  peripheral 
plexuses  and  terminal  ganglia.  The  great  gangliated 
cords  lie  partly  in  front  and  partly  on  the  side  of  the 
vertebral  column,  extending  from  the  base  of  the  skull 
to  the  coccyx.  The  number  of  ganglia  in  general  terms 
corresponds  to  the  .vertebra?  against  which  they  arc 
placed,  except  in  the  neck,  where  there  are  only  three 

1.  Quain's  Anatomy,   vol.   ili,   part  2,   1895.  p.   357. 

2.  Arch,   of  Xeurol.  and   Psycho-Pathol.,   vol.   ill,   Nos.   1   and  2, 
1900,   p.   6. 


635941 


ganglia.  The  connection  between  the  gangliated  cords 
and  the  cerebrospinal  system  is  brought  about  by  short 
filaments  called  communicating  rami,  which  are  of  two 
kinds,  one  consisting  chiefly  of  medullated  fibers  and 
the  other  of  pale  fibers.  The  medullated  fibers  of  the 
white  communicating  rami  proceed  from  both  roots  of 
the  spinal  nerves,  but  to  a  great  extent  from  the  an- 
terior, and  pass  to  the  sympathetic  cord.  Not  all  of 
the  spinal  nerves,  however,  furnish  these  rami.  In  man 
it  is  believed  that  they  exist  from  the  first  dorsal  to 
the  first  or  second  lumbar  nerves,  and  perhaps  also  to  the 
third.  The  gray  communicating  rami  pass  between  all 
of  the  spinal  nerves  and  the  sympathetic  cord.  The 
fibers  arise  in  the  nerve  cells  of  the  ganglia  of  the  sym- 
pathetic cord,  and  enter  the  primary  anterior  division 
of  a  spinal  nerve. 

As  not  specially  germane  to  the  present  topic,  the  in- 
terfunicular  rami,  the  efferent  rami,  the  great  pre- 
vertebral  plexuses,  the  peripheral  plexuses,  and  finally, 
the  monocellular  ganglia,  need  not  be  discussed. 

The  general  plan  of  arrangement  of  the  sympathetic 
supplied  to  the  head,  quoting  Langley,3  is  as  follows : 

The  upper  part  of  the  thoracic  spinal  cord  sends  out  fibers  by 
the  anterior  roots  of  the  spinal  nerves  of  this  region.  These 
fibers  make  no  halt  at  the  ganglia  until  they  reach  the  superior 
cervical  ganglion.  This  is  a  relay  station  for  the  sympathetic 
nerve  supply  for  the  whole  of  the  head.  In  it  all  the  nerve 
fibers  form  nerve  endings,  synapses,  as  they  are  called  by 
Foster.  Each  nerve  cell  sends  off  a  nerve  fiber  which  runs  to 
the  periphery,  where  it  branches  and  supplies  a  group  of  un- 
striped  muscle  or  gland  cells.  On  the  course  of  a  nerve  impulse 
from  the  spinal  cord  to  the  periphery,  there  are,  then,  two 
nerve  cells,  one  with  cell  body  in  the  spinal  cord,  the  other 
with  cell  body  in  the  local  sympathetic  ganglion. 

The  centrifugal  fiber  of  the  first  nerve  cell  is  called 
by  Langley  the  preganglionic  fiber,  by  Kb'lliker  the 
fiber  of  Lhe  first  order;  that  of  the  second  nerve  cell 
the  post-ganglionic  fiber  (Langley),  or  motor  fiber  of 
the  second  order  (Kolliker).  The  majority  of  post- 
ganglionic  fibers  of-  the  superior  cervical  ganglion  pass 
to  the  fifth  cranial  nerve  and  are  distributed  with  its 
sensory  fibers;  for  example,  the  pupillodilator  fibers 
and  other  fibers  destined  to  the  eye  pass  to  the  oph- 
thalmic branch  of  the  fifth  and  the  long  ciliary  nerves. 

3.  Text-Book  of  Physiology,  edited  by  E.  A.  Schafer,  vol.  ii,  1900. 


Vasoconstrictor  fibers  to  the  iris  run  in  the  interna, 
carotid  plexus,  and  not,  according  to  Francois-Franck, 
in  the  cervicogasserian  strand.  There  are  also  post- 
ganglionic  fibers  for  the  superior  cervical  ganglion 
which  proceed  to  the  third  and  to  the  sixth  cranial 
nerves,  which  might  be  supposed,  as  Langiey  suggests, 
to  convey  vasomotor  fibers  of  the  vessels  of  the  ocular 
muscles,  but  thus  far  experiments  have  failed  to  prove 
that  they  have  this  function.4  In  other  words,  we  come 
to  study  that  part  of  a  system  of  efferent  ganglionated 
nerves  which  relates  to  the  eye,  a  system,  to  quote  from 
Gaskell,  which  is  characterized  by  the  fineness  of  its 
fibers,  which  are  always  medullated  when  they  leave 
the  central  nervous  system ;  by .  the  presence  on  each 
of  these  fine,  medullated  fibers,  in  some  part  of  its 
course,  of  a  ganglion  cell,  from  which  fibers  of  the 
same  physiologic  character  pass  to  the  end-organ,  and 
we  remember  in  this  study  that  this  system  includes  not 
only  the  cells  of  the  sympathetic,  but  also  vagrant  motor 
cells,  such  as  are  found  in  the  course  of  the  accessory 
vagus,  in  the  ganglion  trunci  vagi,  and  in  the  course  of 
the  third  nerve  in  the  ciliary  gariglion. 

II.    DISTRIBUTION    OF    THE    SYMPATHETIC    TO    THE    EYE. 

The  sets  of  sympathetic  fibers  which  pass  to  the  eye 
and  its  adnexa,  following  Thane's  classification,  may  be 
described  as  follows : 

1.  The  Pupillodilator  Fibers. — These  arise  from 
the  first,  second  and  third  dorsal  nerves,  which  are  con- 
nected with  the  superior  cervical  ganglion  by  means  of 
slender  cords  which  belong  to  the  group  of  the  gray 
communicating  rami.  They  pass  upward  in  the  ascend- 
ing or  carotid  branch  of  the  first  cervical  ganglion  and 
arrive  at  the  plexus  around  the  internal  carotid  artery 
and  the  gasserian  ganglion.  They  reach  the  eyeball 
through  the  nasal  branch  of  the  ophthalmic  nerve,  or 
the  first  division  of  the  fifth,  by  means  of  its  long 
ciliary  nerves,  which  perforate  the  sclerotic  and  are  dis- 

4.  Jendrassik  divides  the  sympathetic  into  two  systems,  namely, 
the  spinal  system  and  the  vagus  system.  He  describes  a  third 
connection  between  the  central  nervous  system  and  the  organs, 
which  is  called  the  dilator  system.  The  duty  of  this  system  is  to 
maintain  a  tonus  acting  antagonistically  to  the  sympathetic  system, 
that  is.  to  Jendrassik's  motor  system.  It  contains  the  dilator 
fibers  of  the  iris  and  of  the  blood  vessels.  For  a  re'sume'  of  Jen- 
drassik's views,  see  Arch,  of  Neurol.  and  Psycho-Pathol..  vol.  ill, 
1900,  pp.  9-13. 


tributed  to  the  ciliary  muscle,  the  iris  and  the  cornea. 
Jt  is  believed  by  some  observers  that  pupillodilator 
fibers  are  also  contained  in  the  seventh  and  eighth  cer- 
vical nerves.  A  minute  filament  passes  with  the  central 
artery  of  the  retina  into  the  eyeball. 

2.  Motor  Fibers  to  the  Involuntary  Muscles  of  the 
Orbit  and  Eyelids. — These,  according  to  Langley,  pro- 
ceed from  the  highest  fourth  or  fifth  dorsal  nerves  and 
their  communicating  rami.     The  involuntary  muscle  of 
the  orbit  which  receives  this  sympathetic  supply  was 
originally  described  in  1858  by  H.   Miiller.     It  is  a 
rudimentary  layer  of  unstriped  muscle  which  bridges 
over    the    sphenomaxillary     fissure     and     infraorbital 
groove,  and  corresponds  to  a  more  largely  developed 
layer  which  is  found  in  the  extensive  aponeurotic  part 
of  the  orbital  wall  in  various  mammalia.    This  muscle, 
usually  called  Midler's  orbital  muscle,  and  sometimes  the 
sphenomaxillary  muscle,  when  it  contracts,  causes  the 
globe  of  the  eye  to  start  forward,  that  is,  to  project 
more  from  the  orbit. 

The  involuntary  muscle  of  the  eyelids  consists  of  a 
layer  of  unstriped  muscular  tissue  in  each  eyelid,  which 
was  also  originally  described  by  Miiller.  The  layer  of  the 
upper  eyelid  arises  from  the  under  surface  of  the  leva- 
tor  palpebrae,  while  that  of  the  lower  springs  from 
the  neighborhood  of  the  inferior  oblique  muscle.  Each 
of  these  layers  is  inserted  near  the  attached  margin  of 
the  tarsus.  According  to  Henle,  some  of  these  fibers 
also  have  a  transverse  course.  The  collection  of  invol- 
untary fibers  in  the  lower  lid  is  much  less  produced 
than  that  in  the  upper.  According  to  Dwight,  the  func- 
tion of  Miiller's  muscle  in  the  upper  lid  is  to  draw  the 
skin  to  the  fold  above  the  tarsus  when  the  lids  are  open. 

3.  The  Vasomotor  Fibers. — In  so  far  as  the  head  is 
concerned,  according  to  Langley,  these  vasoconstrictor 
fibers  are  given  off  in  the  dog  and  cat  chiefly  by  the 
second,  third  and  fourth  dorsal  nerves.     It  is  probable 
that  vasodilator  fibers  also  exist.5 

5.  Onuf  (see  Note  2)  has  prepared  a  functional  topography 
of  the  sympathetic  nerves  and  their  correlations  in  the  cat,  as 
established  on  the  ground  of  physiologic  experiment.  As  he  him- 
self points  out,  an  important  drawback  to  this  topography  is  that 
it  does  not  relate  to  man,  but  predominately  to  the  cat.  It  may 
be  interesting  to  quote  from  this  the  following :  According  to 
Budge,  Salkowski  and  other  observers,  the  pupil-dilating  fibers  of 
the  cervical  sympathetic  are  derived  in  part  from  the  seventh 
and  eighth  cervical  nerves  through  their  communicating  raml. 


4.  Secretory  Fibers. — These  are  derived,  in  so  far  as 
the  submaxillary  gland  is  concerned,  from  the  third, 
fourth  and  fifth  dorsal,  and  are  interesting  to  us  because, 
according  to  Langley,0  the  results  of  physiologic  inves- 
tigations on  the  salivary  glands  may  be  applied  with 
little  change  to  the  lachrymal  glands,  which  in  their 
histologic  and  physiologic  characters  resemble  albu- 
minous salivary  glands.  Their  cranial  secretory  fibers 
come  through  the  lachrymal  branch  of  the  fifth  nerve. 
Their  sympathetic  fibers  are  derived  from  the  cervical 
sympathetic  and  the  blood  vessels  of  the  gland. 

III.    THE  RELATION  OF  THE  SYMPATHETIC  TO  THE  LACH- 
.  RYMAL  SECRETION. 

Eeasoning  from  analogy,  one  would  expect  that  stim- 
ulation of  the  cervical  sympathetic,  which  causes  secre- 
tion from  the  salivary  glands,  would  also  give  rise  to 
secretion  from  the  lachrymal  glands,  and  this,  in  fact, 
is  usually  stated  to  be  one  of  its  well-established  effects. 
Authors,  however,  are  not  in  accord  on  this  point. 
Campos7  thus  reviews  the  contradictory  evidence :  Her- 
zenstein,  although  he  failed  to  obtain  any  result  by  sec- 
tion of  the  sympathetic  cord  below  the  superior  cervical 
ganglion,  or  by  excitation  of  its  upper  end,  neverthe- 
less believes  that  the  sympathetic  determines  a  secre- 
tion of  tears  different  from  that  which  is  produced  by  the 
trigerninus.  Wolferz  and  Demtschenko8  have  provoked 
lachrymal  secretion  by  excitation  of  the  sympathetic, 
while  Eeich  observed  a  similar  result  in  only  a  few  cases. 
Arloing,  experimenting  on  the  bullock  and  goat,  failed 
to  obtain  any  result  by  exciting  the  upper  end  of  the 
vagosympathetic  cord,  while  its  section  was  imme- 
diately followed  by  hypersecretion.  Tepliachine,  on  the 
other  hand,  arrived  at  exactly  opposite  conclusions. 
Campos'  own  experiments  have  led  him  to  believe  that 

Langley,  however,  denies  that  any  of  the  pupil-dilating  fibers  are 
derived  from  the  cervical  nerves.  He  also  denies  that  the  latter  give 
origin  to  the  vasoconstrictor  and  vasodilator  fibers  for  the  head. 
The  chief  nerve  for  dilatation  of  the  pupil  for  the  nictitating 
membrane  and  for  Miiller's  muscle  arises  from  the  first  dorsal. 
Dilator  fibers  for  the  pupil,  motor  fibers  for  the  nictitating  mem- 
brane and  Miiller's  muscle  are  also  derived  from  the  second  and 
third  dorsal,  and  a  few  motor  fibers  for  the  nictitating  membrane 
from  the  fourth  dorsal,  perhaps,  also,  from  the  fifth  dorsal. 

6.  Text-Book   of   Physiology,    edited   by    E.    A.    Schafer,    vol.    i  : 
The  Salivary  Glands,  by  J.  N.  Langley.  p.  475. 

7.  Archiv  d'Ophthalmologie,  vol.  xvii,  p.  529. 

8.  Archiv  f.  Physiologic,  Bd.  vi,  1872,  p.  191. 


stimulation  of  the  upper  end  of  the  cervical  sympathetic 
does  not  cause  lachrymal  secretion,  and  that  its  sec- 
tion in  man  is  without  influence  on  the  normal  hu- 
midity of  the  eyes  and  on  lachrymation.  Levinsolm/' 
after  section  of  the  cervical  sympathetic,  or  removal  of 
the  superior  ganglion  in  monkeys,  noted  lachrymation 
on  the  operated  side,  which  was  most  noticeable  im- 
mediately after  the  operation,  and  had  disappeared  on 
the  following  day.  This  lachrymation,  he  concludes,  i- 
due  to  the  vascular  hyperemia  which  follows  the  section 
and  therefore  the  sympathetic  should  not  be  considered 
the  nerve  of  secretion  for  the  lachrymal  gland.10 

IV.      THE     INFLUENCE    OF    THE     SYMPATHETIC     ON     TIIK 
MOVEMENTS  OF  THE  IRIS — THE  CILIOSPINAL  CEN- 
TER AND  THE  MYDRIATIC  TRACT  OF  THE  PUPIL. 

The  mechanism  of  the  dilatation  of  the  pupil,  and 
whether  the  presence  of  a  distinct  muscular  structure. 
to  which  the  name  dilatator  pupillse  has  been  given. 
should  be  admitted,  have  occasioned 'much  discussion.11 
Langley  and  Anderson6  have  summarized  the  matter  as 
follows : 

1.  Dilatation  of  the  pupil  may  be  due  to  the  action 
of  the  sympathetic  vasoconstrictor  fibers,  stimulation  of 
which  causes  either  a  decrease  in  the  quantity  of  blood 
in  the  iris,  so  that  it  shrinks,  or  a  longitudinal  con- 
traction of  the  radial  arteries  of  the  iris,  which  cans*-- 
dragging  of  the  sphincter  outward. 

2.  Dilatation  may  be  caused  by  contraction  of  ra- 

9.   Arcbiv  f.  Ophthalmologie,  Bd.  Iv,  1902.  p.  144. 

10.  In  this   connection   it   is   interesting  to  note   that   section   of 
the   cervical   sympathetic    has    no    observable    permanent    effect    on 
the  salivary  gland,  and  it  causes  no  paralytic  secretion :  the  primary 
dilatation   of  the  blood   vessels   soon   disappears.      Excision   of   the 
superior  cervical  ganglion  is  not  followed  by  any  certain  effect  on 
the  salivary  gland   (Langley). 

11.  This,  subject    Is    too    extensive    to    admit    of    much    elabora- 
tion in  the  present  paper.     Those  who  are  interested  in  the  litera- 
ture  of   the   subject   and   in   the   controversies   which    have  arisen 
concerning  the  presence  or  absence  of  a  dilatator  pupilla?  may,  with 
advantage,   consult :      Frank    Baker,   the   Anatomy   of   the   Eyeball. 
System  of  Diseases  of  the  Eye.  edited  by  Norris  and  Oliver,  vol.  i. 
p.   186 ;   George  A.   Piersol,   The  Microscopical  Examination  of  the 
Eyeball,  Ibid.,  p.  279:  Heese.  Ueber  den  Einfluss  des  Sympatheticns 
auf  das  Auge.  insbesondere  auf  die  Irisbewegung.  Archiv  f.  d.  ges. 
Physiolog.,   Bd.   lii,  1893 :   Gaskell,   Innervation  of  the  Sympathetic 
Nerves  in  Relation  to  the  Dilator  of  the  Eye ;  J.  N.   Langley  and 
II.    K.   Anderson,    The   Mechanism   of   the   Movements   of   the    Iris. 
Journal  of  Physiology,  vol.  xiii,  1892. 


9 

dially  arranged  muscular  fibers,  a  view  maintained  by 
Henle,  Budge,  Sappey,  Kolliker,  and  many  others. 

3.  The  dilatation  may  be  due  to  inhibition  of  the 
sphincter  muscle,  that  is,  as  Griinhagen  expressed  it, 
the  sympathetic  may  be  regarded  as  an  "erschlaffungs- 
nerv"  of  the  sphincter,  or,  as  Francois-Frank  expressed 
it,  the  sympathetic  dilator  nerves  of  the  iris  may  act 
in  the  same  manner  as  the  dilator  nerves  of  the  vessel, 
and  suspend  the  activity  of  the  constrictor  nerves.  Gas- 
kell,  referring  to  Griinhagen's  contention  that  the  ra- 
dial fibers  in  the  posterior  limiting  membrane  of  the 
iris  are  not  true  muscular  fibers,  agrees  with  him  and 
does  not  see  the  necessity  of  assuming  the  presence  of  a 
dilator    of    the    pupil,  because    one    may    assume    that 
the  nerves  which  dilate  the  pupil  act  on  the  sphincter 
muscle ;  in  other  words,  that  they  are  inhibitory  nerves, 
or  dilator  nerves  of  that  muscle.      According  to  him. 
the  sphincter  muscle  of  the  iris  represents  an  example 
of  a  muscular  structure  which  is  supplied  by  two  nerves 
of  opposite  character,  one  a  motor  and  the  other  an  in- 
hibitory nerve. 

4.  Dilatation  may  be  due  to  relaxation  of  the  elas- 
ticity of  part  of  the  ciliary  region  and  the  anterior  part 
of  the  choroid,  which  pulls  backwards  the  iris. 

5.  Dilatation  may  be  caused  by  the  simultaneous  ac- 
tion of  more  than  one  of  the  above-mentioned  causes. 

Both  Frank  Baker  and  George  A.  Piersol11  think  that 
the  combined  anatomic  and  physiologic  evidence  of 
the  existence  of  a  radially  arranged  dilator  muscle 
is  conclusive;  while  Jessop12  maintains  that  he  has 
never  seen  any  fibers  that  could  be  compared  in  thick- 
ness with  the  sphincter  of  the  pupil,  or  capable,  physic- 
ally, of  overcoming  the  sphincter  fibers  and  producing 
dilatation  of  the  pupil.  Whichever  of  these  two,  in 
some  respects  diametrically  opposed  views,  is  accepted, 
there  is  no  question  that  the  dilating  impulse  trans- 
mitted to  the  iris  passes  through  the  cervical  sympa- 
thetic, and,  in  general  terms,  along  what  is  called  the 
mydriatic  tract  of  the  pupil,  which  may  now  be  briefly 
outlined,  as  follows:  It  proceeds  from  a  center  in  the 
medulla  as  far  as  the  second  dorsal  nerve.  It  then 
follows  the  communicating  branch  of  this  nerve  to  the 
cervical  sympathetic,  and  reaches  the  plexus  around  the 
internal  carotid  artery.  From  this  point  it  passes  to 

12.   Ophthalmic  Surgery  and  Medicine.  London.  1898. 


10 

the  nasocilian-  branch  of  the  nasal  nerve,  which  as  the 
long  ciliary  nerves  supply  the  muscular  tissue  of  the  iris. 

Collins  and  Onuf,0  after  comparing  the  results  of 
various  investigators,  find  that  the  pupillodilating 
fibers  occur  with  the  greatest  constancy  in  the  first 
dorsal  and  almost  as  constantly  in  the  second  dorsal, 
to  less  extent  and  less  constantly  in  the  third  dorsal 
and  the  eighth  cervical,  and  least  constantly  in  the 
seventh  cervical  and  fourth  dorsal.  This  distribution 
varies,  not  only  with  the  species  of  the  animal,  but  also 
individually  in  the  same  species. 

Experimenting  in  1841,  Budge  and  Waller13  deter- 
mined the  origin  of  the  pupil-dilating  fibers  of  the 
cervical  sympathetic  to  be  in  the  spinal  cord  in  a  re- 
gion situated  between  the  exits  of  the  sixth  cervical 
and  fourth  dorsal  or  thoracic  nerves.  Since  that  time 
this  center  has  been  called  Budge's  center,  or  the  cilio- 
spinal  center.'  Budge's  conclusions  have  been  both  con- 
firmed and  denied,  confirmed  by  Dastre  and  Morat,  and 
denied  by  Salkowski  and  Knoll,  the  former  placing  the 
origin  of  the  pupil-dilating  fibers  in  the  medulla,  the 
latter  in  the  anterior  corpora  quadrigemina.  Referring 
to  these  contradictory  statements,  Collins  and  Onuf 
declare  that  although  experimental  as  well  as  clinical 
evidence  is  in  favor  of  the  existence  of  a  ciliospinal 
center,  it  has  not  been  definitely  proven. 

Several  observers,  notably  Francois-Franck, .  main- 
tain that  not  all  the  pupil-dilating  fibers  are  derived 
from  the  cervical  sympathetic,  but  that  some  of  them 
reach  the  gasserian  ganglion  by  way  of  the  roots  of 
the  trigeminal  nerve,  and  this  view,  according  to  Onuf 
and  Collins,14  is  confirmed  by  the  results  of  their  experi- 
ments. The  possibilit}r  that  the  sympathetic  may  also 
contain  pupil-contracting  fibers  is  a  subject  to  which 
reference  will  be  made  in  another  portion  of  this  paper. 

V.     CONCERNING    THE     NATURE     OF     THE     CILIARY     GAN- 
GLK)N,    WITH    SPECIAL    REFERENCE    TO    ITS    RELA- 
TION    TO    THE    SYMPATHETIC     SYSTEM     AND    A 
CONSIDERATION  OF  THE  EFFECTS  ON  THE 
EYE  OF  LESIONS  OF  THIS  STRUCTURE. 

The  ciliary, 'ophthalmic,  or  lenticular  ganglion,  as  it 
is  variously  called,  is  a  center  for  the  supply  of  nerves, 

13.  Vierordfs   Archiv   f.    Physiolog.    Heilkunde,    1852. 

14.  See  Footnotes  2  and  5,  pp.    91,    92,    for    experiments    which 
these  authors  think  demonstrate  their  belief. 


11 

motor,  sensory  and  sympathetic,  to  the  eyeball.  This 
small,  reddish  body,  composed  of  cells  of  the  multipolar 
variety,  is  placed  between  the  external  rectus  muscle 
and  the  optic  nerve  at  the  back  of  the  orbit,  and  is 
joined  from  behind  by  branches  from  the  trigeminus, 
the  oculomotor  and  the  sympathetic  nerves.  A  slender 
filament  derived  from  the  nasal  branch  of  the  ophthal- 
mic constitutes  its  long  or  sensory  root,  a  twig  from 
the  branch  of  the  third  nerve  going  to  the  inferior 
oblique  muscle,  its  short  or  motor  root,  and  a  small 
nerve  from  the  cavernous  plexus  of  the  sympathetic,  its 
middle  or  sympathetic  root.  Much  difference  of  opin- 
ion has  existed  and  still  exists  concerning  the  nature 
•of  this  ganglion,  i.  e.,  whether  it  should  be  considered 
as  a  spinal,  sympathetic,  or  mixed  sensitivo-motor  gan- 
"glion. 

Schwalbe13  believes  that  the  ciliary  ganglion  is  a 
spinal  ganglion  and  belongs  entirely  to  the  oculo- 
motor, a  view  which  has  also  been  maintained  by  Anto- 
nelli,  and  confirmed,  in  so  far  as  its  spinal  nature  is 
concerned,  by  Goldberg16  in  his  researches  on  the  em- 
bryo of  chickens.  Hess,  Bemak  and  Phisalix  main- 
tain the  spinal  nature  of  the  ganglion  and  that  it  be- 
longs %to  the  trigeminus.  Van  Gehuchten,  who,  like 
Betzius  and  von  Michel,  has  employed  the  Golgi  method 
in  his  investigations,  is  inclined  to  a  belief  contrary 
to  that  of  the  authors  just  named,  and  thinks  that  the 
ciliary  ganglion  is  to  be  reckoned  with  the  spinal  gan- 
glia. " 

Peschel17  found  a  diminutive  ganglion,  which  is  sit- 
uated on  the  oculomotor  of  the  rabbit,  to  be  composed 
of  cerebrospinal  ganglion  cells.  In  addition  to  this, 
however,  he  observed  a  well-developed  system  of  sym- 
pathetic ganglion  elements  in  the  orbit  which  was  sub- 
ject to  a  great  many  variations,  but  was  always  demon- 
strable. 

Holzmann18  has  histologically  examined  the  ciliary 
ganglion  in  a  number  of  animals,  and  found  it  of  va- 
rious composition — in  frogs  of  spinal  cells,  in  birds  of 
-cerebrospinal  elements,  in  rabbits  of  the  same  struc- 
ture, but  also  the  widespread  sympathetic  elements  in 
the  orbit  previously  described  by  Peschel ;  in  dogs  great 

15.  Jenaische  Zeitschr.,  Bd.   xiii,  1879. 

16.  Archiv  f.  Mikroskopie,  Bd.  xxxvii. 

17.  Graefe's  Archiv  f.   Ophth.,   Bd.  xxxix.   2. 

18.  Morphologische  Arbelten.  Bd.  vi. 


12 

individual  variations,  as  well  in  the  position  as  in  the 
structure  of  the  ganglion,  but  with  the  sympathetic  ele- 
ments prevailing;  and  in  cats  practically  entirely  sym- 
pathetic cells,  spinal  elements  being  at  most  in  the  form 
of  under-developed  or  pigmy  cells. 

Michel's19  researches  show  that  the  ganglion  in  man 
and  calves  is  a  sympathetic  structure.  An  interesting 
fact  observed  by  Holzmann  and  Schmiedeberg  is  on  the 
action  of  atropin  on  the  different  animals  in  corres- 
pondence with  the  different  histologic  structure  of  the 
ganglion.  In  those  species  of  animal,  namely,  in  which 
the  ganglion  is  mainly  or  entirely  composed  of  sym- 
pathetic cells,  atropin  produces  the  most  marked  par- 
alysis of  the  iris  and  ciliary  bod}',  while  in  birds,  in 
which  the  ganglion  cells  partake  of  the  nature  of 
cerebrospinal  cells,  there  is  practically  no  atropin  ac- 
tion. Kolliker  believes  entirely  in  the  sympathetic  na- 
ture of  the  ciliary  ganglion,  and  rests  his  belief  on  his- 
tologic studies,  especially  such  as  have  been  made  by 
Rauber,  Retzius  and  von  Michel,  according  to  which 
the  ciliary  ganglion  is  composed  only  of  multipolar 
sympathetic  cells,  and,  on  the  other  hand,  on  the  ex- 
periments of  Langley  and  Anderson,20  and  Langen- 
dorff,21  who  believe  it  is  a  sympathetic  ganglion. 

Lodato,22  who  has  experimented  with  dogs,  affirms 
that  the  ganglion  is  composed  partly  of  sympathetic 
elements  and  partly  of  cerebrospinal  elements.  This, 
according  to  him,  is  true  for  the  dog  and  very  probably 
for  other  mammalia,  and  consequently  for  man.  In 
short,  he  believes  it  is  a  mixed  ganglion,  sensitivo- 
motor  in  nature,  in  which  the  motor  part  naturally  de- 
pends on  the  sympathetic  and  the  sensitive  part  on  the 
trigeminus.  The  double  nature  of  the  ganglion  has 
also  been  maintained  by  Krause. 

Bernheimer,23  whose  observations  were  made  on  the 
ganglia  of  apes  and  monkeys,  and  who  gives  a  good 
summary  of  the  previous  literature  on  this  subject, 
from  which  several  quotations  have  been  made,  is  un- 
willing to  commit  himself  entirely,  but  doubts  the  pure 

19.  Trans.    Eighth    Intern.    Ophth.    Congress,    Edinburgh,    1894. 
p.    195. 

20.  Journal  of   Physiology,   vol.   xil,   1894. 

21.  Pflueger's  Archiv  f.  Physiologic,   Bd.   Ivi. 

22.  Archivio   di    Ottalmologia,   vol.    vii,    1900 ;    Abstract   Annale& 
d'Oculistique,  T.  cxxvi.  1901,  p.  230. 

23.  Archiv  f.  Ophth.,  Bd.  xlix,  1897. 


13 

sympathetic  nature  of  the  ganglion,  Avhile  Bach's24  re- 
searches indicate  that  the  ciliary  ganglion  in  all  prob- 
ability is  of  a  sympathetic  nature.  Marina,25  who  has 
elaborately  studied  the  neuron  of  the  ciliary  ganglion, 
concludes  that  the  ciliary  ganglion  in  apes  very  prob- 
ably possesses  few  spinal  and  numerous  sympathetic 
cells.  Jegerow  considered  the  ciliary  ganglion  homol- 
ogous to  a  posterior  root  ganglion. 

Bach26  finds  that  injections  of  nicotin  into  the  orbit 
of  the  cat  cause  paralysis  of  the  sphincter  of  the  pupii 
very  quickly.  Xow,  inasmuch  as  nicotin  paralyzes  only 
sympathetic  nerve  cells,  this  indicates  the  presence  of 
such  cells  in  the  orbit,  and  naturally  suggests  the  sym- 
pathetic nature  of  the  ciliary  ganglion,  although  it  does 
not  disprove  the  possibility  of  its  being  of  a  mixed  na- 
ture. 

Langendorff27  formerly  advocated  the  spinal  nature 
of  the  ciliary  ganglion,  but  as  the  result  of  recent 
investigations  he  has  changed  his  opinion  and  now 
believes  it  to  be  a  sympathetic  ganglion. 

It  will  therefore  be  seen  from  this  imperfect  resume 
that  the  nature  of  this  nervous  structure  has  not  been 
positively  determined  in  any  one  species  of  animal, 
and  that  it  differs  greatly  in  different  species.  All 
things  considered,  however,  the  weight  of  evidence  is 
in  favor  of  the  ganglion  belonging  to  the  sympathetic 
system,  at  least  in  so  far  as  man  is  concerned.  As- 
suming, therefore,  the  probable  sympathetic  nature  of 
this  structure,  a  few  words  may  be  said  on  its 
relation  to  the  pupil  movements.  As  is  well 
known,  Langley  and  Anderson  have  noticed  that 
the  erectores  pilorum  of  the  cat  are  under  the 
influence  of  certain  communicating  rami  of  the  an- 
terior spinal  roots,  but  that  this  influence  is  exerted  not 
directly,  but  with  the  help  of  nerve  fibers  which  arise 
in  the  ganglion  of  the  sympathetic  cord.  In  the  same 
manner,  according  to  the  observation  of  these  authors 
and  according  to  the  researches  of  Langendorflv  the 
oculomotor  nerve  acts  not  directly  on  the  sphincter  of 
the  pupil,  but  in  association  with  the  ciliary  ganglion. 
According  to  Langendorff,  electrical  stimulation  of  the 

24.  Ibid.,  xlvii,  1899,   p.  68. 

25.  Deutsch.  Zeitschr.  f.  Nervenheilkunde,  xiv,  1899.  p.  356. 

26.  Bericht   iiber  die   XXX   Versammlung  Ophthal.    Gesellschaft. 
Heidelberg.  1902.  p.  16. 

27.  Klin.  Monatsbl.   f.  Augenheilk.,  xxxviii,   1900,  p.  307. 


14 

trunk  of  the  oculomotor  of  the  cat  in  the  cranial  cavity 
never  produces  contraction  of  the  pupil.  Only  when 
quite  quickly  after  death  it  is  stimulated,  a  distinct  con- 
traction proceeding  from  the  oculomotor  trunk  can  be 
observed.  After  a  short  space  of  time  this  result  ceases 
to  exist.  If,  instead  of  the  oculomotor  branch,  the 
short  ciliary  nerves  of  the  orbit  are  stimulated  some 
time  after  death,  it  is  still  possible  to  obtain  a  pupil 
contraction.  Langendorff  concludes,  therefore,  that  the 
myotic  fibers  of  the  oculomotor  nerve  do  not  traverse 
the  ganglion  uncombined,  but  that  ganglion  cells 
are  inserted  in  the  pupil-contracting  path,  early  death 
of  which  is  responsible  for  the  failure  of  the  irritation 
effect,  which  ought  to  follow  the  proximal  stimulation 
of  the  nerve  trunk. 

Apolant,28  writing  concerning  the  nature  of  the 
ciliary  ganglion,  maintains  that  after  section  of  the  ocu- 
lomotor in  the  skull,  the  degeneration  of  the  entire  oculo- 
motor fibers  in  the  ganglion  can  be  traced  only  to  the 
cells  of  the  ganglion  and  not  further  on.  This  result 
he  explains  on  the  supposition  that  those  root-fibers 
\vhich  belong  to  the  oculomotor  end  in  the  ganglion,  as 
von  Michel  has  shown  in  Golgi  preparations,  and  that 
with  the  cells  of  the  ciliary  ganglion  a  new  neuron  be- 
gins for  the  fibers  which  pass  to  the  ciliary  muscle  and 
the  sphincter  of  the  pupil. 

To  put  this  matter  in  another  form  and  using  the 
words  of  Sherrington,  the  smaller  root-cells  of  the  oculo- 
motor send  their  nerve  fibers  to  the  ciliary  ganglion, 
whence,  as  from  a  sympathetic  ganglion,  fresh  nerve 
cells  emit  fibers  to  the  ciliary  muscle  and  constrictor- 
pupillae. 

Marina,25  after  pointing  out  that  there  is  much  dif- 
ference of  opinion  as  to  the  exact  position  of  the  center 
of  the  pupil  movements,  for  example,  that  Voelker 
and  Hensen  place  the  center  in  the  anterior 
portion  of  the  oculomotor  nucleus,  von  Bechterew 
in  the  central  gray  matter  of  the  third  ven- 
tricle, Mendel  in  the  ganglion  habenula,  and 
that  in  man  the  Westphal-Edinger  and  later  the 
Darkschewitsch  nucleus  have  been  claimed  as  the  center, 
although  Bernheimer  thinks  that  the  last-named  nu- 
cleus does  not  belong  to  the  oculomotor  group  at  all, 
and  has  nothing  to  do  with  pupil-reaction,  maintains 

28.   Archiv  f.  Anat.  u.  Physiol.,  Physiologische  Abth..  1896.  p.  344. 


15 

that  the  ciliary  ganglion  is  the  center  for  pupil-move- 
ment. He  agrees  with  Bernheimer  that  five-sixths  of 
the  cells  of  the  ciliary  ganglion  degenerate  after  cau- 
terization of  the  cornea,  and  that  therefore  five-sixths 
of  these  cells  are  of  sensory  nature  and  are  active  in 
the  sensibility  of  the  cornea.  Xicotin  experiments  in- 
dicate that  the  sensory  cells  of  the  ciliary  ganglion  are 
of  spinal  nature.  Opticociliary  neurotomy  and  exen- 
teration  of  the  bulb,  or,  in  other  words,  injury  to  those 
nerves  which  supply  the  intraocular  muscles,  cause  all 
of  the  cells  of  the  ganglion  to  be  more  or  less  de- 
generated. It  follows,  therefore,  that  the  greatest  part 
of  the  ganglion  cells  possesses  a  motor  function,  namely, 
the  innervation  of  the  sphincter  of  the  iris,  and  he  con- 
cludes, as  before  stated,  that  the  ciliary  ganglion,  in 
apes  at  least,  very  probably  contains  few  spinal  and 
numerous  sympathetic  cells,  and  returns  to  his  contention 
that  the  ganglion  is  really  the  center  for  pupil  move- 
ments. Now  Bernheimer,23  also  experimenting  with  apes, 
finds  that  there  are  roots  of  nerve  fibers  which  supply 
not  alone  the  ganglion  cells  but  also  the  cornea,  hence 
lesion  of  the  ganglion,  for  this  structure  is  alike  in 
apes  and  man,  ought  to  produce  a  corneal  destruction 
as  well  as  fixation  of  the  pupil,  if  it  really  is,  as  Marina 
maintains,  the  center  for  pupil  movement,  an  associa- 
tion which  has  not  been  observed.  Otherwise  it  would 
be  necessary  to  assume  an  elective  primary  disease  of 
those  cells  which  supply  nerves  to  the  iris  and  ciliary 
body,  and  this  is  exactly  what  Marina  does,  although 
Bernheimer  is  unwilling  to  agree  with  him.  In  this 
connection  it  is  interesting  to  revert  to  the  fact  that 
many  years  ago  ophthalmoplegia  interna,  that  is,  par- 
alysis of  the  intraocular  muscles,  the  iris  and  ciliary 
body,  was  ascribed  by  Jonathan  Hutchinson  to  disease 
of  the  lenticular  ganglion,  and  although  it  is  customary 
to  say  at  the  present  time  that  he  was  mistaken  in  this 
view  of  the  pathology  of  these  cases,  if  Marina's  re- 
sults are  to  be  considered  trustworthy,  and  his  assump- 
tion of  an  elective  primary  disease  of  those  cells  which 
supply  the  iris  and  ciliary  body  be  accepted,  he  was 
exactly  right. 

The  effect  of  lesion  of  the  sympathetic  on  the  cornea 
has  been  given  a  new  significance  by  Emil  von  Grosz.29^ 
If  it  is  true,  he  argues,  as  the  researches  of  Bernheimer 

29.   Ungarische  Beltrage  zur  Augenheilkunde,  Bd.  ii.  1900,  p.  295. 


16 

and  others  indicate,  that  fibers  from  the  ciliary  gan- 
glion of  apes  go  to  the  cornea,  and  if,  further,  it  is  true 
that  the  ciliary  ganglion,  according  to  its  nature,  be- 
longs to  the  sympathetic,  and  that  only  trigeminus 
libers  pass  through  it,  then  the  degenerated  paths  which 
have  been  demonstrated  may  be  identical  with  the  fibers 
which  influence  the  nourishment  of  the  cornea.  It  fol- 
lows that  it  is  reasonable  to  ascribe  the  cause  of  the 
neuroparalytic  keratitis  to  disease  of  the  ciliary  gan- 
glion, because  only  trigeminus  fibers  pass  the  ganglion, 
therefore  section  of  the  ganglion  of  Gasser  or  of  the 
trigeminus  is  associated  only  with  anesthesia  and  could 
produce  no  lesions  in  the  ganglion  or  in  the  cornea. 
On  the  other  hand,  the  sensitiveness  of  the  cornea  could 
be  sympathetically  affected  if  the  ganglion  was  dis- 
eased, and  this  is  actually  the  case.  He  believes,  in 
other  words,  that  the  suppurative  keratitis  which  occurs 
in  the  eyes  of  animals  and  men  after  section  of  the 
trigeminus  or  disease  or  injury  to  the  gasserian  gan- 
glion is  brought  about  by  infection  which  comes  from 
the  conjunctiva,  the  lachrymal  sac,  or  the  external  at- 
mosphere and  which  is  established  because  the  anesthesia 
and  drying  of  the  cornea  can  not  resist  injuries,  but 
that  the  cause  of  true  neuroparalytic  keratitis  of  men, 
which  is  identical  with  keratomalacia  and  keratone- 
crosis,  is  due  to  a  degeneration  of  the  cells  of  the  ciliary 
ganglion  which  may  occur  from  cachexia,  hemorrhage 
or  from  injury.  This  view,  however,  is  not  substantiated 
from  the  experimental  standpoint,  inasmuch  as  Ander- 
son,30 who  has  extirpated  the  ciliary  ganglion  in  kit- 
tens, never  observed  trophic  changes. 

Ordinarily  excision  of  the  ciliary  ganglion  increases 
dilatation  of  the  pupil,  and,  as  Jegerow31  has  shown, 
this  dilatation  is  greater  than  after  section  of  the  nerve. 

Anderson  was  able  to  obtain  in  kittens  from  which 
he  had  removed  the  ciliary  ganglion  a  paradoxical  pu- 
pilloconstriction  of  the  denervated  sphincter,  just  as 
after  extirpation  of  the  superior  cervical  ganglion  in 
animals  slight  stimulation  produces  a  paradoxical  pu- 
pillary dilatation  which  has  been  attributed  to  increased 
tone  in  denervated  unstriped  muscle.  Anderson,  how- 
ever, has  shown  that  his  observations  on  paradoxical 
pupilloconstriction  were  not  to  be  explained  by  increased 

30.  Jour,  of  Physiol.,  vol.  xxviii,  No.  3. 

31.  Arch.  Slaves  de  biol..   Paris.  1887.  T.  iii.  p.  322. 


17 

tone,  hut  increased  excitability  brought  about  by  very 
slight  stimuli. 

Finally,  we  come  to  consider  what  the  effect  on  the 
tension  of  the  eyeball  is  when  the  ciliar}'  ganglion  is 
extirpated,  as  it  has  been  suggested  that  this  operation 
might  replace  the  one  of  excision  of  the  cervical  sympa- 
thetic ganglion  in  glaucoma. 

Rohmer32  has  extirpated  the  ciliary  ganglion  in  seven 
cases  of  absolute  glaucoma,  and  although  he  claims  that 
pain  was  ultimately  alleviated,  in  all  cases  tension  was 
never  reduced  to  normal.  In  other  words,  as  J.  Herbert 
Parsons,  commenting  on  this  paper,  has  said,  the  re- 
sults of  Rohmer's  work  afford  little  support  to  the  view 
that  the  increased  intraocular  tension  of  glaucoma  is 
in  any  way  associated  with  the  ciliary  ganglion.  There 
is  even  less  experimental  evidence,  as  he  further  re- 
marks, for  this  hypothesis  than  for  that  which  attrib- 
utes this  function  to  the  superior  cervical  ganglion. 
Rohmer  believes  that  the  ciliary  ganglion  controls  the 
vascularization  of  the  anterior  segment  of  the  eye,  and 
the  superior  cervical  ganglion  that  of  the  posterior  seg- 
ment, and  in  this  manner  each  influences  the  intraocular 
tension. 

VI.      THE    RELATION    OF    THE    SYMPATHETIC    TO    ACCOM- 
MODATION AND  REFRACTION. 

Morat  and  Doyon33  maintain  that  after  section  of  the 
sympathetic  there  is  a  diminution  in  the  size  of  the  an- 
terior crystalline  lens  images,  and  after  irritation  of 
the  sympathetic  an  enlargement  of  the  same  images. 
Therefore,  they  conclude  that  the  sympathetic  exer- 
cises an  inhibitory  influence  on  accommodation  and  has 
an  antagonistic  action  to  the  third  nerve.  In  other 
words,  according  to  them,  the  sympathetic  is  an  in- 
hibitory nerve  for  the  accommodation  and  influences 
its  function  at  the  distant  point,  the  oculomotor,  of 
course,  adapting  the  eye  for  near  objects.  These  ob- 
-« -nations  have  not  been  confirmed  by  Langley  and  An- 
derson or  by  Hess  and  Heine.34  The  latter  observers, 
for  example,  found  that  if  the  sympathetic  is  exposed  in 
a  dog  and  a  registering  needle  inserted  into  the  equator 
of  the  eye,  and  the  sympathetic  irritated  the  pupil 

32.  Annales  d'Oculistiqne,  July,  1902. 

33.  Archiv  de  Physiol..  vol.  iii.  1901.  p.  507. 
.".4.   Archiv  f.  Ophthalmol..  xlvi.  1898.  p.  259. 


18 

promptly  dilates,  but  the  needle  remains  quiet ;  in  other 
words,  the  sympathetic  can  dilate  the  pupil,  but  does 
not  influence  the  ciliary  muscle.  There  is  under  these 
circumstances,  sometimes,  a  diminution  in  refraction, 
which  Hess  and  Heine  attribute  to  the  disturbing  in- 
fluence of  the  more  peripheral  portions  of  the  cornea 
and  lens,  made  possible  by  the  dilatation  of  the  pupil. 

These  views  Avere  contested  by  Dor  at  the  meet- 
ing of  the  Thirteenth  International  Congress  in  Paris, 
and  therefore  Rohmer  and  Dufour35  have  returned  to 
the  subject  and  made  numerous  experiments,  and  en- 
deavored especially  to  elucidate  two  points,  namely,  the 
alteration  in  the  refraction  which  undoubtedly  occurs 
after  stimulation  of  the  sympathetic  and  which  may 
be  demonstrated  by  retinoscopy  and  the  change  in  the 
size  of  the  images  on  the  lens  which  Dor  asserts  takes 
place.  They  find  that  the  alteration  in  refraction  noted 
in  certain  instances  on  dilatation  of  the  pupil  is  not 
necessarily  due  to  any  actual  change  in  the  lens  and 
show  that  the  difficulty  of  being  quite  certain  of  an 
increase  of  diminution  in  the  size  of  the  very  small 
images  on  the  surface  of  the  lens  is  extremely  great. 
Morat  and  Doyon  state  that  the  image  may  enlarge  by 
as  much  as  a  third  or  even  a  half  of  its  own  diameter : 
now  in  man,  at  all  events,  an  alteration  in  size  of 
slightly  less  than  half  has  been  shown  to  correspond 
to  a  change  in  refraction  of  7  D.,  much  greater 
than  the  alteration  in  refraction  admitted  by  Hess  and 
Heine.  Eohmer  and  Dufour  do  not,  moreover,  find  that 
close  relationship  to  exist  betAveen  the  pupil  dilatation 
and  the  alteration  in  the  size  of  the  images  on  Avhich  the 
French  observers  have  laid  considerable  stress.  Indeed, 
their  results  are  directly  contrary  to  those  of  Morat 
and  Doyon.  In  other  words,  they  do  not  find  that  the 
sympathetic  has  any  power  of  causing  negative  accom- 
modation. 

The  effect  of  stimulation  of  the  cervical  sympathetic 
in  rabbits  on  the  refraction  of  the  eye  has  recently  been 
investigated  by  Terrien  and  Camus.30  They  found 
that  stimulation  of  the  cervical  sympathetic  after  sec- 
tion induces  in  all  cases  an  increase  in  the  refraction  of 
the  eye  on  the  same  side,  this  increase  varying  from 

33.  Ibid.,  liv,  Abth.  3 ;  see,  also,  abstract  Ophthal.  Review. 
January,  1903. 

36.  Ibid.,   June,   1902. 


19 

1  to  2.05  D.  This  change  in  refraction  does  not  co^ 
exist  with  the  dilatation  of  the  pupil,  but  begins  later 
and  is  of  shorter  duration.  The  authors  do  not  furnish 
a  satisfactory  explanation  of  the  phenomena  which 
they  observed,  although  they  eliminated  the  possibility 
of  elongation  of  the  globe  or  increase  of  corneal  curva- 
ture being  due  to  muscular  action  by  cutting  the  ex- 
ternal ocular  muscles.  Experiments  with  Purkinje's 
images  to  ascertain  whether  the  refraction  of  the  lens 
changed,  gave  no  definite  results. 

VII.    THE    RELATION    OF    THE    SYMPATHETIC    TO    INTRA- 
OCULAR TENSION. 

As  long  ago  as  the  times  of  Pourfour  de  Petit,  that 
is  in  147,  it  was  observed  that  after  section  of  the  sym- 
pathetic the  eye  was  softer,  and  this  fact  was  afterwards 
verified  by  Claude  Bernard  and  other  experimenters, 
and  very  early  it  was  suggested  that  a  primary  dis- 
ease of  the  sympathetic  ganglia  of  the  neck  might  be 
the  basal  cause  of  glaucoma.  In  1867,  Adamtlk,37  and 
about  the  same  time  Wegner,38  discussed  the  relation- 
ship between  intraocular  tension  and  the  cervical  sym- 
pathetic in  the  neck,  and  the  influence  of  the  latter 
on  the  development  of  glaucoma,  although  their  ex- 
perimental researches  were  not  entirely  in  accord.  Eul- 
enberg  and  Guttman,n9  discussing  this  matter,  have- 
summarized  the  results  of  these  observers  somewhat 
as  follows :  Adamiik  found,  after  cutting  the  neck 
sympathetic  in  chloroformed  cats,  a  diminution  of  the 
intraocular  tension  of  1  to  2  mm.  This  lessening  was 
of  short  duration  and  it  was  soon  followed  by  a  supple- 
mentary elevation  of  tension.  Irritation  of  the 
cut  sympathetic  with  induction  currents  caused  an  ele- 
vation of  intraocular  tension  of  2  to  4  mm.,  which  re- 
mained for  a  time  and  then  gradually  disappeared.  The- 
diminution  of  the  tension  was  coincident  with  the 
pupil  enlargement  and  the  exophthalmos,  and  was 
ascribed  by  Adamiik  to  lessening  of  the  blood-stream. 
The  early  elevation  of  tension  he  attributed  to  the  ac- 
commodative apparatus.  According  to  him,  two  fac- 
tors were  potent  in  the  production  of  changes  in  the 

37.  Med.  Centralbl.,  1866,  No.  36;  Ibid..  1867,  No.  28;  Abstract 
Annales  d'Ocullstique,  Ivlii,  p.  5. 

38.  Archiv  f.  Ophthalmol.,  Bd.  xii.  Abth.  2.  1866,  p.   1. 

39.  Die  Pathologic  des   Sympathicus  auf  Physiologischer  Griind- 
lage.  Berlin,  1873. 


20 

/ 

intraocular  tension  under  the  influence  of  irritation  of 
the  sympathetic  which  worked  in  opposite  ways,  and  ac- 
cording as  one  predominated  or  did  not  predominate 
the  tension  rose  or  fell,  the  one  factor,  that  is,  the  vaso- 
motor  apparatus,  causing  lessening  of  the  intraocular 
tension,  the  other  inherent  in  the  internal  ocular 
muscles,  probably  the  ciliary  muscle,  giving  rise  to  an 
elevation  of  intraocular  tension. 

Hippel  and  Griinhagen  also  observed  that  in  the  early 
stage  of  sympathetic  irritation  in  cats  there  is  an  ele- 
vation and  later  a  dropping  of  the  intraocular  tension. 
These  results  were  explained  by  a  contraction  of  the 
orbital  muscles  and  the  vessels  of  the  eye.  Elevation 
of  the  intraocular  tension  after  irritation  of  the  sym- 
pathetic was  likewise  noted  by  Francois-Franck. 

Adamiik,  in  disagreement  with  Hippel  and  Griin- 
hagen, after  excluding  every  possible  error,  satisfied 
himself  that  elevation  of  intraocular  tension  depended 
on  contraction  of  the  inner  muscles  of  the  eye,  that  is, 
of  Miiller's  fibers  of  the  choroid  and  perhaps  a  portion 
of  the  ciliary  muscle.  These  sympathetically  inner- 
vated muscles  caused  the  bulb  to  start  forward  and  in 
that  manner  an  increase  in  the  depth  of  the  anterior 
chamber  was  determined.  Irritation  of  the  sympathetic 
in  curarized  animals,  according  to  this  observer,  pro- 
duced narrowing  of  the  arteries  and  filling  of  the  veins 
of  the  retina,  and  therefore  he  believed  that  the  chief 
cause  of  glaucoma  depended,  not  so  much  on  an  eleva- 
tion of  tension  as  on  inhibition  of  the  venous  circula- 
tion which  is  induced  when  there  is  loss  of  the  elasticity 
of  the  sclera  as  the  result  of  inflammatory  processes. 
Wegner  also  found  diminution  of  intraocular  tension, 
from  4  to  8  mm.,  after  section  of  the  sympathetic, 
which  he  attributed  to  a  paralytic  widening  of  the 
blood  vessels. 

Horner,  and  later  his  student  Xicati,40  writing  con- 
cerning paralysis  of  the  sympathetic  from  various  path- 
ologic conditions  in  the  neck,  noted  a  diminution  in  the 
tension  of  the  eye  which  was  present  in  two  periods  of 
the  paralysis,  that  is,  in  the  period  which  was  analogous 
in  his  phenomena  to  those  observed  in  animals  after 
section  of  the  cervical  sympathetic,  and  in  the  period  in 
which  the  symptoms  were  modified  by  secondary 
atrophies.  Therefore  it  was  concluded  that  this  fall  in 

40.  La  Paralysie  du  Nerf  Sympathiqne  Cervical,   1873. 


tension  was  independent  of  any  excess  of  vasculariza- 
tion.  Abadie,  believing  that  the  symptoms  of  glaucoma 
can  be  explained  by  an  excitation  of  the  vasodilator 
fibers  of  the  ocular  blood  vessels,  suggested  in  1898  that 
relief  from  this  disease  might  be  obtained  by  section  of 
the  sympathetic  in  the  neck,  and  soon  afterward  the 
first  operation  of  resection  of  the  cervical  sympathetic 
was  performed  by  Jonnesco. 

In  still  more  recent  times  numerous  experiments  have 
been  made  on  the  effect  of  irritation  and  section  of  the 
sympathetic  on  the  intraocular  tension.  Thus  Neu- 
scheuler41  has  observed  that  narcosis  itself  causes  an 
elevation  of  the  intraocular  tension  of  from  2  to  6  de- 
grees in  Fick's  tonometer,  while  irritation  of  the  sym- 
pathetic causes  an  elevation  of  at  least  10  degrees.  Sec- 
tion of  the  sympathetic  reduces  the  tension  on  the  same 
side  from  3  to  6  degrees,  but  only  after  twenty  to  forty- 
five  minutes.  Observations  of  this  character  made  in 
rabbits  were  confirmed  in  cats,  who  have  a  deeper  an- 
terior chamber,  and  it  was  further  noted  that  in  these 
animals  irritation  on  one  side  caused  an  elevation  of 
tension  in  the  opposite  eye. 

Using  the  method  of  slow  irritation  of  the  cervical 
sympathetic,  produced  by  inserting  a  small  foreign  body 
into  the  superior  ganglion,  Lodato,42  by  means  of  the 
Leber  apparatus,  studied  the  relations  between  secre- 
tion and  excretion  of  the  aqueous  fluid  in  the  eye  on  the 
same  side  as  the  irritated  sympathetic,  and  proved  that 
there  was  a  diminution  of  the  flow  from  the  apparatus 
to  the  anterior  chamber  and  therefore  increased  intra- 
ocular tension.  He  further  demonstrated  that  this  rise 
of  tension  is  independent  of  dilatation  or  constriction 
of  the  blood  vessels,  inasmuch  as  he  was  able  to  note  an 
increase  of  tension  in  cases  of  superficial  and  deep  vaso- 
dilatation  and  vasoconstriction.  Finally,  he  demon- 
strated that  the  increase  of  tension  is  absolutely  inde- 
pendent of  the  state  of  the  pupil.  The  increase  of  ten- 
sion may  last  for  several  months  in  the  dog,  with  but 
slight  variation. 

The  result  of  excision  of  the  cervical  ganglion  of  the 
sympathetic  on  intraocular  tension  in  rabbits  has  been 
investigated  by  Selenkowski  and  Eosenberg,43  and  while 

41.  Nagel's     Jahresbericht    f.     Ophthalmologie,    yol.     xxx,     1890. 
p.  120. 

42.  Klin.  Monatsbl.  f.  Augenheilk.,  xli.  Bd.  i.  1903,  p.  329. 

43.  Xagel's  Jahresb.   f.  Ophtalraol..   xxxii.   1900.   p.    003. 


22 

they  found  a  reduction  of  intraocular  tension,  it  was 
always  exceedingly  temporary  in  its  effect,  lasting  some- 
times only  three  to  five  days  and  never  more  than  twelve 
days.  They  naturally  contend,  therefore,  that  Abadie's 
theory  of  glaucoma  is  untenable. 

Hertel,44  experimenting  on  young  animals  (ten  to 
twenty  day  old  rabbits)  found  a  lowering  of  tension 
about  one  hour  after  excision  of  the  ganglion,  as  de- 
termined by  manometer  and  tonometer,  but  this  lasted 
only  five  days.  He  thinks  the  varying  results  reported 
by  observers  may  depend  on  the  difference  of  time  in 
noting  tension,  and  believes  there  is  a  relation  between 
vessel  fullness,  myosis  and  lowered  tension.  When  the 
vessels  return  to  their  natural  state  and  myosis  lessens, 
tension  returns  to  normal. 

Levinsohn,45  who  has  quite  recently  reviewed  the  en- 
tire subject  of  the  influence  of  the  cervical  sympathetic 
on  the  eve,  experimenting  on  apes  and  other  animals, 
has  noted  that  sympathetic  section  primarily  diminishes 
the  intraocular  tension,  which  in  a  very  short  time  re- 
turns to  normal.  A  similar  result  was  noted  when  only 
the  large  branches,  but  not  the  carotid  branches,  were 
cut,  a  fact  which  might  indicate  that  the  diminution 
in  pressure  was  not  only  due  to  vessel  but  to  muscle 
changes. 

Joseph  Collins48  believes  that  the  diminution  of  intra- 
ocular tension  caused  by  extirpation  of  the  cervical  sym- 
pathetic depends  on  a  reduction  of  the  blood  pressure 
and  that  this  procedure  acts  on  the  blood  vessels  of  the 
eye  something  as  nitroglycerin  does.  In  other  words, 
he  suggests  that  the  diminution  of  intraocular  tension 
must  be  dependent  on  the  general  dilatation  that  occurs 
in  the  carotid  system  after  the  ganglion  has  been  ex- 
tirpated. 

VIII.    THE  OCULAR  PHENOMENA  WHICH  FOLLOW  GALVAN- 
IZATION AND  FARADIZATION  OF  THE  CERVICAL 
SYMPATHETIC. 

To  a  certain  extent  these  phenomena  have  already 
been  discussed,  but  they  may  in  general  terms  be  re- 
ferred to  again  in  a  summary  manner.  The  effects 
which  electrical  currents  when  applied  to  the  s}rmpa- 

44.  Archiv  f.  Ophtalmol..   Bd.  xlix,   1900,  p.  432. 

45.  Ibid.,  Iv.  1902,  p.  144. 

46.  Personal   communication.   March  19.  190.°>. 


23 

thetic  produce  must  be  studied  in  their  relation  to:  (a) 
the  pupil  of  the  same  side;  (b)  the  contralateral  pupil, 
that  is,  the  pupil  of  the  opposite  side;  (c)  the  color  of 
the  iris;  (d)  the  position  of  the  nictitating  membrane 
and  the  globe  of  the  eye  and  the  width  of  the  palpebral 
fissure;  (e)  the  blood  vessels  of  the  conjunctiva,  the  iris 
and  the  fundus  oculi;  (f)  the  tension  of  the  eyeball; 
(g)  the  secretion  of  the  lachrymal  gland. 

1.  Electrical  stimulation  of  the  cervical  sympathetic 
produces  on  the  side  stimulated  a  dilatation  of  the  pupil 
as  a  result  of  the  contraction  of  the  dilatator  pupillae. 
Whether  this  dilator  should  be  regarded  as  a  muscular 
structure  or  only  as  a  contractile  substance,  or  whether 
the  phenomenon  depends  on  inhibition  of  the  sphincter 
has  been  thoroughly  discussed  and  need  not  again  be 
reviewed. 

According  to  Lodato,  if  in  the  superior  ganglion  a 
foreign  body  is  inserted,  there  is  produced  a  slowly- 
acting  state  of  irritation  of  the  cervical  sympathetic. 
The  pupil  dilates,  but  the  dilatation  is  rarely  a  lasting 
one.  Such  a  pupil  reacts  but  slightly  to  the  action  of 
light,  but  if  light  is  flashed  into  the  opposite  pupil, 
there  is  a  reaction  of  the  one  on  the  operated  side.  In 
these  cases  there  is  a  distinct  grade  of  retinal  anemia, 
to  which  Lodato  attributes  the  pupillary  phenomenon. 

2.  In  1893,  Dogiel  made  the  interesting  observation 
that  when  the  cervical  sympathetic  was  stimulated  on 
one  side,  there  was  on  the  opposite  side  a  contraction  of 
the  pupil,  and  he  explained  this  phenomenon  by  assum- 
ing that  there  was  a  physiologic  connection  with  the 
pupil-dilating  center  of  the  one  and  the  pupil-contract- 
ing center  of  the  other  side,  although  such  anatomic  con- 
nection had  never  been  demonstrated. 

Schenck  and  Fuss47  have  confirmed  Dogiel's  observa- 
tion, but  believe  that  in  dogs  and  cats  this  result  de- 
pends on  the  consensual  pupil-reflex,  inasmuch  as  the 
increased  light  impulse  which  enters  the  eye  on  the 
electrically  irritated  side,  owing  to  the  mydriasis  which 
is  produced,  causes  reflex  narrowing  of  the  pupil  on 
the  opposite  side.  In  rabbits,  in  which  there  is  no  con- 
sensual pupil-reflex,  they  could  not  in  opposition  to  the 
statement  of  Dogiel  establish  a  narrowing  of  the  contra- 
lateral  pupil. 

47.   Archiv  f.  die  Gesaramte  Physiol.,  Ixxv.  1899.  p.  110. 


24: 

Tuemianzevv48  has  investigated  this  subject  most  elab- 
orately and  believes  that  Dogiel's  reaction  is  not  pro- 
duced by  changes  in  the  eye  on  the  side  of  the  irri- 
tated sympathetic,  that  it  can  not  be  considered  en- 
tirely as  the  result  of  the  consensual  pupillary  reaction, 
as  maintained  by  Schenck  and  Fuss,  but  that  it  repre- 
sents a  newly  discovered  reflex,  transmitted  through  the 
sympathetic  fibers,  joining  the  cranial  nerves  'in  the  re- 
gion of  the  cavernous  sinus. 

There  would  seem  to  be  some  difference  in  effect  fol- 
lowing galvanization  and  faradization  of  the  sympa- 
thetic, if  the  observations,  but  so  far  as  I  know  uncon- 
firmed, of  Katyschew49  may  be  credited,  Avhich,  briefly 
summarized,  are  these:  Galvanization  of  the  superior 
triangle  of  the  neck  may  cause  dilatation  of  the  pupiL 
but  also  contraction,  anodal  opening  producing  a  rapid 
dilatation,  while  cathodal  closing  is  usually  not  asso- 
ciated with  constant  changes.  If  this  region  is  fara- 
dized,  the  pupil  contracts,  either  immediately  or  at 
some  later  date,  contraction  occurring  on  the  side  of  the 
electrode,  on  the  other  side,  or  on  both  sides.  He  be- 
lieves that  through  this  faradization  nerve  fibers  still 
unknown  are  irritated,  which  act  as  inhibitory  fibers  to 
those  sympathetic  nerves  going  to  the  pupil  dilator. 
It  is  likely  that  they  come  from  the  spinal  cord  and 
pass  through  the  carotid  plexus. 

3.  The  same  observer  has  noted  that  after  faradiza- 
tion and  contraction  of  the  pupil  there  is  a  change  in  the 
color  of  the  iris,  which  he  attributes  to  varying  displace- 
ment of  the  iritic  fibers.    So  far  as  I  know,  this  observa- 
tion has  not  been  confirmed. 

4.  Electrical  stimulation  of  the  cervical  sympathetic- 
causes  retraction  of  the  nictitating  membrane,  which, 
according  to  Langley's  observations,  is  much  more  prom- 
inently seen  in  the  cat  and  dog  than  in  the  rabbit.     In 
the  higher  animals,  as  in  man  and  apes,  the  nictitating 
membrane  is  rudimentary.     In  addition  to  this,  there 
is  separation  of  the  lids,  the  movement  being  greater  in 
the  lower  than  in  the  upper  eyelid.     Finally,  there  is 
well-marked  projection  of  the  eye,  or  proptosis ;  in  other 
words,  the  direction  of  its  axis  being  straight  forward. 
Eckhard  is  of  the  opinion  that  this  proptosis  is  more 
apparent  than  real,  and  is  manifest  chiefly  because  the 
1 • — 

48.  Ibid..   Ixix.  1897,   p.   199. 

49.  Archiv  f.  Psych,  u.  Nervenkrank.,  vol.  vili,  1877-78,  p.  G24. 


25 

lower  eyelid  is  drawn  decidedly  backwards  and  there- 
fore there  is  a  greater  exposure  of  the  bulbus.  This 
appearance  is  well  marked  in  animals,  especially  dogs, 
and  has  also  been  observed  by  Wagner  in  the  head  of  a 
decapitated  criminal.  There  is  no  doubt  that  such  phe- 
nomena depend  on  the  action  of  the  unstriped  muscle 
in  the  region  already  described,  in  so  far  as  animals 
are  concerned.  It  is  perhaps  not  so  well  established  in 
human  beings.50 

Curiously  enough,  Heese51  has  found  that  irritation 
of  the  sympathetic  causes  in  rabbits,  in  contrast  to  the 
general  rule,  a  retraction  of  the  eyeball  into  the  orbit, 
and  this  is  due  to  a  contraction  of  the  orbital  vessels 
and  the  anemia  which  is  thereby  caused.  In  other 
words,  the  sympathetic  nerve  displays  its  effect  on  the 
eyeball  in  two  different  ways,  that  is,  by  a  contraction 
of  the  unstriped  muscles  of  the  orbit,  Miiller's  muscle, 
and  by  vasomotor  influence.  If  Miiller's  muscle  con- 
tracts there  is  protrusion,  but  if  there  is  a  contraction 
of  the  orbital  vessels,  then  there  is  a  sinking  in;  pre- 
dominance of  the  one  influence  will  cause  exophthal- 
mos,  predominance  of  the  other,  enophthalmos. 

5.  Stimulation  of  the  cervical  sympathetic  is  fol- 
lowed by  contraction  of  the  blood  vessels  of  the  con- 
junctiva, of  the  iris,  and  perhaps  by  alteration  in  the 
caliber  of  the  vessels  of  the  retina,  although  it  is  dif- 
ficult to  get  satisfactory  evidence  with  reference  to  the 
last-named  phenomena. 

Rockwell  and  Beard32  investigated  the  effect  of  gal- 
vanization of  the  sympathetic  on  the  vessels  of  the  .eye- 
ground,  using  a  current  of  from  10  to  25  elements. 
Roosa,  who  watched  the  retina  under  these  circum- 
stances, saw  at  first  a  hyperemia  and  afterward  an  ane- 
mia of  its  vessels,  while  Loring  noted  only  decided  filling 
of  the  veins,  and  another  observer  only  contraction  of 
the  arteries.  Slow-acting  mechanical  irritation  of  the 
sympathetic,  according  to  Lodato,  produces  retinal 
anemia  in  dogs. 

6.  The  effect  of  electrical  currents  on  the  tension  of 
the  eyeball,  when  these  were  applied  to  the  cervical  sym- 
pathetic,  as  well  as  their  influence  in  increasing  the 
secretion  of  the  lachrymal  gland,  have  already  been  de- 
tailed. 

50.  Consult  Die  Neurol.  d.  Auges,  Wilbrand  and  Saenger,  i,  p.  545. 

51.  Archiv  f.  die  Gesammte  Physiol.,  Bd.  52,  1892,  p.  535. 

52.  Medical   and  Surgical    Electricity,   1871. 


IX.    THE    OCULAR    PHENOMENA    WHICH    FOLLOW    INJURY 

TO   THE   SYMPATHETIC   IN   THE   NECK   CAUSED   BY 

DISEASE  OR  BY  SECTION  OF  THE  SYMPATHETIC 

CORDS,  OR  BY  THE  EXTIRPATION  OF  THE 

SYMPATHETIC    CERVICAL    GANGLIA. 

In  connection  with  this  subdivision  of  the  subject, 
we  have  to  study:  (a)  The  condition  of  the  pupil;  (b) 
the  width  of  the  palpebral  fissure;  (c)  the  position  of 
the  nictitating  membrane;  (d)  the  position  of  the  ocular 
globe;  (e)  the  state  of  the  conjunctival  blood  vessels 
and  the  secretion  of  the  lachrymal  gland;  (f)  the  intra- 
ocular tension;  (g)  alterations  in  the  vascular  supply 
of  the  uveal  tract  and  the  retina;  (h)  trophic  changes 
in  the  globe;  (i)  the  shape  of  the  cornea,  and  in  gen- 
eral, the  refraction  of  the  eye. 

It  is  well  known  that  the  sympathetic  nervous  sys- 
tem exercises  a  tonic  action  on  certain  of  the  struc- 
tures which  it  supplies;  for  example,  in  the  cervical 
sympathetic,  the  vasoconstrictor  fibers,  the  pupillo- 
dilator  fibers  and  the  constrictor  fibers  to  the  unstriped 
muscle  of  the  eye  and  its  appendages,  are,  to  quote  the 
words  of  Langley,  in  a  state  of  constant  action,  broken 
only  by  a  state  of  inhibition,  occurring  in  the  central 
nervous  system;  hence  section  of  the  cervical  sympa- 
thetic will  cause  a  paralytic  effect  in  those  tissues  which 
are  in  a  state  of  tonic  contraction. 

(1)  As  long  ago  as  1727,  Pourfour  du  Petit  noted  that 
division  of  the  cervical  sympathetic  was  followed  by 
contraction  of  the  pupil,  and  this  observation  was  con- 
firmed particularly  by  the  studies  of  Claude  Bernard  in 
1851,  and  later  by  those  of  Brown-Sequard  in  1852. 
All  subsequent  experiments,  as  well  as  clinical  observa- 
tions, which  indicated  that  the  cervical  sympathetic 
had  been  destroyed  by  injury  or  disease,  have  confirmed 
these  results,  and  we  now  know  that  when  the  myd- 
riatiu  path  in  the  sympathetic,  that  is,  the  path  which 
contains  the  pupillodilator  fibers,  is  divided,  there  is 
necessarily  prompt  contraction  of  the  pupil  on  the  cor- 
responding side. 

A  matter  of  some  interest  is  to  determine  whether 
the  effect  on  the  pupil,  as  well  as  the  other  structures 
of  the  eye,  is  greater  after  excision  of  the  superior  cer- 
vical ganglion  than  after  section  of  the  sympathetic 
cord.  Claude  Bernard  noted  greater  paralytic  results 
from  excision  than  from  section,  but  Schiff,  Callenfels 


27 

and  Pye-Smith  failed  to  find  any  difference.  This  ques- 
tion has  been  recently  investigated  from  the  experi- 
mental standpoint  by  Levinsohn,53  and  he  has  found, 
experimenting  with  apes,  that  if  the  sympathetic  is 
cut  on  one  side  and  the  ganglion  removed  in  the  other, 
the  difference  in  the  pupillary  width  is  not  very  great, 
amounting  to  no  more  than  1/2  mm.,  but  in  cases  where, 
respectively,  the  sympathetic  is  cut  or  the  ganglion  re- 
moved, the  pupillary  difference  is  demonstrable  and  the 
pupil  always  smaller  on  the  side  on  which  the  ganglion 
is  removed.  This  of  itself  is  not  sufficient  evidence  to 
declare  that  the  ganglion  exercises  an  individual  tonus 
over  the  nerve,  but  when  the  ganglion  is  removed,  the 
nerve  having  previously  been  resected,  additional  con- 
traction takes  place,  and  this,  it  would  seem,  indi- 
cates that  the  ganglion  has  a  different  and,  as  it  were, 
a  stronger  action  on  the  eye  than  the  nerve  trunk  itself. 
Furthermore,  irritation  in  some  animals  of  the  per- 
ipheral cut  ends  of  the  nerve  trunk  causes  no  addi- 
tional change  in  the  pupil,  and  the  same  occurs  when 
the  lower  part  of  the  ganglion  is  irritated.  Excitation 
of  the  upper  part  of  the  ganglion,  however,  produces  a 
prompt  response,  and  therefore  the  indications  are  that 
an  individual  tone  is  exercised  by  the  ganglion.  The 
tonus  remaining  in  the  ganglion  is  dependent  on  higher 
oerebrospinal  twigs.  Langendorff  believes  that  the  su- 
perior cervical  ganglion  possesses  a  distinct  tonic  ac- 
tivity. 

A  matter  of  great  importance  is  the  permanence  of 
the  myosis  after  section  of  the  sympathetic  or  extirpa- 
tion of  the  ganglion.  According  to  Langley,  this  varies 
greatly  in  different  animals.  In  the  frog  the  develop- 
ment of  paralytic  symptoms  in  the  eye  after  section 
of  the  sympathetic  is  gradual;  in  the  rabbit  after 
twenty-four  hours  the  pupil  begins  to  dilate,  and  on 
the  third  to  the  fifth  day  again  becomes  small  and  re- 
mains smaller  than  normal ;  in  all  animals  there  is  some 
•degree  of  return  to  normal  after  section.  In  the  cat 
and  dog  section  of  the  cervical  sympathetic  causes  a 
permanent  diminution  in  the  size  of  the  pupil;  in  the 
rabbit  this  phenomenon  is  much  less  marked.  Levinsohn 
has  also  noticed  that  the  myosis,  as  well  as  the  other 
paralytic  symptoms,  gradually  becomes  less  apparent  but 

53.  See  footnote  45  :  also,  Bericht  iiber  die  XXX  Versammlung 
•der  Ophth.  Gesellschaft.  Heidelbei-g.  1903.  p.  238. 


28 

does  not  entirely  disappear,  and  long  ago  Pye-Smith  ob- 
served that  permanent  contraction  of  the  pupil  was 
more  nearly  a  result  without  exception  than  the  other 
phenomena. 

Langendorff54  maintains  that  myosis  produced  by  ex- 
cision of  the  cervical  sympathetic,  as  well  as  the  accom- 
panying narrowing  of  the  palpebral  fissure  and  retrac- 
tion of  the  globe,,  may  persist  for  }rears.  After  extirpa- 
tion of  the  superior  cervical  sympathetic  ganglion  all 
the  phenomena  of  paralysis  of  the  sympathetic  nerve, 
especially  contraction  of  the  pupil,  are  at  first  pro- 
nounced. These  phenomena,  however,  gradually  become 
less  marked,  and  may  disappear  or  even  give  place  to  the 
opposite  condition.  This  change  to  the  opposite  condi- 
tion always  occurs  when  the  animal  is  anesthetized, 
several  days,  or  weeks,  or  months  after  the  operation, 
or  when  it  is  subjected  to  sensory  or  emotional  stimuli. 
It  is  possible  that  dyspnea  also  may  have  the  same 
effect.  Putting  this  in  another  way,  it  may  be  stated, 
according  to  Langendorff,  that  following  extirpation  of 
the  upper  cervical  ganglia  the  phenomena  of  sympa- 
thetic paralysis  which  appear  on  the  corresponding  side 
soon  after  the  operation  may  after  a  time  disappear  and 
give  place  to  the  signs  of  sympathetic  excitation,  which, 
although  moderate,  become  very  pronounced  under  an- 
esthesia. 

It  would  seem  to  make  no  difference  in  regard  to  the 
age  of  the  animals  experimented  on,  and  within  the 
limits  already  expressed,  the  species  of  animal  employed. 
Extreme  narrowing  of  the  pupil,  for  example,  has  been 
seen  by  Hertcl  after  the  removal  of  the  ganglion  in 
young  animals  (ten  to  twenty  day  rabbits),  and  al- 
though the  other  symptoms  were  more  or  less  transient, 
the  myosis  was  permanent,  but  as  time  went  on  it  also 
ceased  to  be  as  complete  as  immediately  after  section. 
M"ot  only  is  there  myosis  when  the  ganglion  is  removed 
and  tne  cord  cut,  but  the  same  result  may  be  obtained, 
as  Levinsohn  has  shown,  when  the  main  branches  are 
divided,  but  neither  the  main  trunk  or  the  secondary 
branches  are  injured.  The  myosis,  however,  is  less 
marked  under  these  circumstances  than  when  the  trunk 
is  divided  or  the  ganglion  extirpated. 

As  has  been  already  mentioned,  Francois-Fraiu  i. 
taught  that  not  all  pupil-dilating  fibers  contained  in  the 

r>4.   Kiln.   Monatsbl.   f.   Augenheilk.,   xxxviii.   1'joo,  p.   120.. 


first  branch  of  the  trigeminal  nerve  are  derived  from 
the  cervical  sympathetic,  but  that  part  of  them  read1, 
the  gasserian  ganglion  by  way  of  the  roots  of  the  tri- 
geminal nerve,  and  Onuf  and  Collins  are  also  con- 
vinced that  not  all  the  mydriatic  fibers  are  contained  in 
the  cervical  sympathetic.'"""' 

Although  section  of  any  portion  of  the  mydriatic 
tract  produces  myosis,  it  does  not  abolish  the  pupil  re- 
flexes, that  is,  the  pupil  on  the  operated  side  will  re- 
spond to  light  stimuli.  Xaturally,  however,  the  so- 
called  sympathetic  reaction  of  the  pupil,  that  is,  the 
pain  or  the  skin  reflex,  is  abolished.  Heiligenthal,00  dis- 
cussing cases  in  which  the  sympathetic  had  been  de- 
stroyed by  diseased  glaflds  in  the  neck,  suggests  that  in 
the  neck  sympathetic  fibers  exist  which  produce  a  widen- 
ing of  the  pupil  as  the  result  of  psychic  impressions. 

According  to  Levinsohn,53  the  myotic  pupil  caused  by 
sympathetic  section  or  gangiiectomy  is  not  affected  by 
the  action  of  cocain.  It  is  slightly  contracted  by  eserin, 
but  less  contracted  on  the  operated  side  than  on  the  non- 
operated  side.  It  is  dilated  by  homatropin,  the  action 
being  slighter  on  the  operated  side  than  on  the  other, 
owing  to  the  smaller  size  of  the  pupil  on  the  operated 
side  and  to  the  damaged  tone  of  the  dilator.  He  has 
further  shown  that  not  only  is  the  action  of  these  drugs 
less  marked  on  the  operated  eye,  especially  in  so  far  as 
eserin  is  concerned,  but  that  it  is  slower  than  normal. 
Furthermore,  the  diminution  in  reaction  is  greater  when 
the  ganglion  is  resected  than  when  the  nerve  is  cut. 
These  facts  he  thinks  prove  that  the  sphincter  is  weak- 
ened by  the  sympathetic  operation,  although  what  con- 
nection the  sphincter  has  with  the  sympathetic  nerve 
is  not  as  yet  known.  Chloroformization  of  animals  on 
whom  sympathectomy  has  been  performed  causes  a 
greater  dilatation  of  the  pupil  on  the  operated  than  on 
the  normal  side.  Gangiiectomy  produces  a  narrower 
pupil  than  sympathectomy,  although  the  reverse  was 
present  before  narcosis.  Deep  narcosis  is  necessary  to 
bring  about  these  changes.  When  intense  narcosis  is 
induced,  this  paradoxical  pupillary  change  is  more  no- 
ticeable after  the  animal  has  somewhat  recovered  from 

55.  See  footnote  14  for  their  experiments  and  for  their  -belief 
that  the  sympathetic  nerve  contains  not  only  the  dilator  but  also 
contracting  fibers  for  the  pupil,  that  is,  contracting  fibers  for. the 
pupil  of  the  same  side. 

."i(j.   Archiv  f.  Psych,  u.  Nervenkrank.,  1900,  p.   79. 


30 

the  anesthetic.  The  normal  pupil  returns  to  its  normal 
narrow  state;  the  other  remains  dilated.  Curare  pro- 
duces dilatation  of  the  pupil  on  the  operated  side  in 
rabbits,  in  monkeys  less  dilatation  on  the  operated  than 
on  the  normal  side,  and  in  cats  greater  dilatation  on  the 
operated  side  as  compared  with  the  non-operated  side. 
This  action  is  due  to  paralysis  of  the  nerve  supplying 
the  sphincter. 

Langendorff/4  writing  concerning  the  paradoxical 
pupillary  dilatation,  that  is  to  say,  that  the  myosis  which 
follows  gangliectomy  is  greater  than  that  which  suc- 
ceeds sympathectomy,  but  that  this  condition  is  true 
only  for  a  period  immediately  succeeding  the  operation, 
inasmuch  as  a  few  hours  later  1;he  difference  begins  to 
disappear,  and  after  one  or  two  days  the  pupil  on  the 
side  on  which  gangliectomy  has  been  performed  may 
even  be  larger  than  that  on  the  side  on  which  sym- 
pathectomy has  been  effected,  summarizes  the  various 
theories  which  have  been  advanced  to  explain  this  con- 
dition, as  follows: 

(a)  The   oculomotor  nerve   meets   with   less   resist- 
ance than  ordinarily  in  the  performance  of  its  func- 
tions.    This  reacts  on  the  focus  where  the  nerve  force 
is  generated.     In  other  words,  the  condition  represents 
an  example  of  the  truth  that  power  is  increased  by  ex- 
ercise and  diminished  by  lack  of  resistance  (Budge). 

(b)  Direct  irritation  of  the  dilator  muscle  by  the 
drug  used  for  the  purpose  of  demonstration,  for  ex- 
ample, an  anesthetic  or  atropin. 

(c)  Vasomotor  changes. 

Langendorff  objects  to  all  of  these  theories,  and  for 
his  arguments  the  reader  should  consult  the  original. 
His  own  theory  is  that  the  explanation  of  the  para- 
doxical pupillary  phenomenon  and  associated  phenom- 
ena depend  on  the  degenerative  processes  in  the  post- 
cellular  nerves  of  the  ganglion.  He  assumes  that  in 
the  smooth  muscles  Avhich,  owing  to  their  sluggish  con- 
tractions, are  probably  not  capable  of  fibrillary  twitch- 
ing, degeneration  of  their  respective  nerves  may  lead  to 
irritative  phenomena  manifesting  themselves  in  contrac- 
tions or  contractures.  If  such  contraction  may  lie  as- 
sumed to  take  place  after  the  removal  of  the  upper  cer- 
vical ganglion  in  the  radial  fibers  of  the  iris  muscle, 
which  is  the  dilatator  of  the  iris,  and  in  the  remaining 
unstriped  muscles  of  the  eye  supplied  by  the  cervical 


31 

sympathetic,  the  phenomena  which  have  been  described 
can  be  explained. 

A  considerable  excision  of  the  sympathetic  must  be 
made  in  order  to  prevent  a  rapid  regeneration,,  and  it 
has  been  shown  that  this  regeneracy  is  moderately  rapid 
in  the  cervical  sympathetic  and  doubtless  in  other  pre- 
ganglionic  sympathetic  fibers.  Langley  states  that  he 
has  found  a  return,  although  not  to  a  full  extent,  of  all 
of  the  functions  of  the  sympathetic  in  a  cat  twenty-four 
hours  after  section,  and  Langendorff57  has  removed  the 
superior  cervical  sympathetic  ganglion  from  animals, 
and  noticed  restoration  of  function  at  the  end  of  105 
days.  The  bearing  of  these  facts  on  operative  work  on 
the  cervical  sympathetic  is  only  too  apparent. 

2-4.  From  the  earliest  days  of  experimentation  on  the 
sympathetic  to  the  present  time,  it  has  been  noted  that 
section  of  the  cervical  sympathetic,  or  its  destruction 
by  disease  or  injury,  in  addition  to  myosis,  will  be  fol- 
lowed by  narrowing  of  the  palpebral  aperture,  projec- 
tion of  the  nictitating  membrane  and  retraction  of  the 
globe  of  the  eye. 

The  narrowing  of  the  palpebral  fissure  has  been  at- 
tributed partly  to  a  predominating  tonus  of  the  orbic- 
ularis,  partly  to  individual  weight  of  the  upper  lid, 
and  partly  to  a  moderate  retraction  of  the  bulbus, 
brought  about  by  a  relaxation  of  Miiller's  orbital  muscle, 
or  by  consecutive  atrophy  of  the  orbital  fat.  Like  the 
myosis,  it  is  more  prominent  after  gangliectomy  than 
after  sympathectomy,  but  is  not  so  permanent  a  phe- 
nomenon. The  tone  of  the  muscles,  according  to  Levin- 
sohn,  injured  by  removal  of  the  sympathetic  is  not  com- 
pletely destroyed,  and  under  certain  circumstances  these 
muscles,  especially  in  some  animals,  may  acquire  an 
increased  irritability.  When  cocain  is  instilled  under 
these  circumstances,  the  same  author  has  demonstrated 
that  although  the  pupil  is  unaffected,  the  palpebral 
fissure  is  slightly  widened,  but  after  the  ganglion  is  re- 
moved cocain  produces  change  neither  in  the  pupil  nor 
in  the  width  of  the  fissure.  This  narrowing  of  the 
lid  'fissure  produces  in  effect  a  form  of  ptosis,  some- 
times called  ptosis  sympathica,  first  described  clin- 
ically by  Horner58  and  attributed  by  him  to  paralysis 
of  the  unstriped  muscular  fibers  of  the  lid,  the  so- 

57.  Abstract,  Lancet.  Oct.  5,  1901. 

58.  Klin.  Monatsbl.  f.  Augenheilk.,  vol.  vii,   1869,  p.  193. 


33 

called  palpebral  muscles  of  Miiller,  an  explanation  which 
has  been  adopted  by  many  other  writers  and  particu- 
larly insisted  on  by  Nicati  in  his  well-known  mono- 
graph on  paralysis  of  the  sympathetic  nerve.  The  slight 
ptosis  after  sympathetic  palsy,  according  to  Wildbrand 
and  Saenger,  manifests  itself  particularly  after  psychic- 
alterations  and  physical  exertions.59 

Inasmuch  as  stimulation  of  the  cervical  sympathetic 
produces  retraction  of  the  nictitating  membrane,  it  is 
natural  that  its  paralysis  or  division  will  cause  a  pro- 
jection of  the  same  structure,  a  phenomenon  which 
is  interesting  in  animals,  but  not  particularly  note- 
worthy in  men  on  account  of  the  rudimentary  nature 
of  this  structure.  The  retraction  of  the  globe  which 
follows  sympathetic  section  has  been  attributed  to  a 
reduction  of  the  volume  of  the  bulbus,  as  was  originallv 
maintained  by  Pourfour  du  Petit  and  Claude  Bernard, 
based  on  observations  on  animals  who  had  survived  some 
time  after  sympathectomy ;  to  atrophy  of  the  fatty  tis- 
sues of  the  orbit ;  and  finally,  to  paralysis  of  the  smooth 
muscles  which  stretch  across  the  floor  of  the  orbital 
cavity. 

Hertel,44  experimenting  on  young  rabbits,  attributes 
this  enophthalmos  to  atrophy  of  the  orbital  fat,  and  not 
to  a  paralysis  of  Miiller's  muscle,  which  he  maintains 
comes  on  only  at  the  end  of  six  weeks.  He  believes 
that  the  elastic  fibers  in  Miiller's  muscle  are  sufficient 
to  hold  the  globe  in  place.  Angelucci  and  others,  like 
the  earlier  experimenters,  have  attributed  this  enoph- 
thalmos to  a  real  smallness  of  the  eye,  that  is,  to  an 
atrophy  of  the  ocular  globe,  a  position  which  later  ex- 
perimenters, notably  Hertel  and  others,  have  not  ad- 
mitted to  be  established. 

5-7.  The  state  of  the  blood  vessels  of  the  conjunctiva 
nud  the  iris  and  the  secretion  of  the  lachrymal  gland 
under  the  influence  of  sympathetic  section  have  been 
fully  described  and  need  not  be  referred  to  again.  The 
same  may  be  stated  in  regard  to  intraocular  tension,  to 
which  a  special  paragraph  has  been  devoted. 

8.     Ophthalmoscopic  and  microscopic  lesions  in  the 

59.  Those  interested  In  the  clinical  study  of  this  question  should 
consult  the  admirable  work  of  Wildbrand  and  Saenger  (see  Note  50). 
pp.  541-558.  It  is  interesting  to  remember  that  the  first  accurate 
study  of  bullet  wound  of  the  sympathetic  and  the  classical  symp- 
toms it  caused  was  made  during  our  Civil  War  by  Drs.  Weir 
Mitchell,  George  Morehouse  and  \V.  W.  Keen. 


33 

eyegroimd  after  sympathetic  section  have  received  con- 
siderable study.  As  long  ago  as  1871  Sinitzin60  found, 
after  extirpation  of  the  superior  sympathetic  ganglion, 
an  increased  vascular  injection  of  the  eyegroimd  on  the 
operated  side.  He  noticed  that  the  choroidal  vessels 
increased  in  volume,  that  their  anastomoses  were  more 
readily  seen,  and  that,  in  general  terms,  the  redness  of 
the  eyegroimd  on  the  operated  side  was  greater  than 
that  on  the  opposite  side. 

Angelucci,01  after  extirpation  of  the  stellate  ganglion 
in  the  new-born  dog,  described  lessening  in  the  devel- 
opment of  the  circumference  of  the  cornea  and  sclera; 
also  atrophy  and  sclerosis  of  the  texture  of  the  iris  and 
choroid  and  the  formation  of  sclerotic  plaques.  He  did 
not,  however,  discover  fundamental  changes  in  the  struc- 
ture of  the  retina.  These  dystrophies  Angelucci  attrib- 
uted to  changes  in  the  blood  vessel  walls,  which  had  al- 
ready been  described  by  Vulpian  and  Giovanni.  Obar- 
rio  has  reported  hemorrhages  in  the  ciliary  body  and 
ciliary  processes  and  less  frequently  in  the  retina  and 
choroid.  These  phenomena  Hertel,  who  quotes  them, 
could  not  substantiate  in  his  experiments.  Neuscheuler 
noted  ophthalmoscopically  vessel  contraction  during 
the  period  of  sympathetic  irritation  and  elevated  ten- 
sion, and  the  opposite  condition  during  the  period  of 
section.  After  sympathectomy  he  observed  widening  of 
the  blood  paths  of  the  uveal  tract,  as  well  as  miliary 
hemorrhages,  and  naturally  suggests  that  therapeutic 
extirpation  of  the  sympathetic  ganglion  from  this  stand- 
point, at  least,  is  not  a  harmless  procedure. 

Doyon,62  writing  concerning  trophic  disturbances  of 
the  eye  after  section  of  the  great  sympathetic  in  the 
neck,  states  that  in  rabbits  this  operation  causes  lesions 
of  the  lid  and  cataract,  and  points  it  out  as  interesting 
that  the  development  of  these  trophic  changes  took 
place  after  section  of  a  centrifugal  nerve,  although  the 
general  conception  is  that  a  lesion  of  sensitive  nerves 
should  be  made  responsible  for  such  conditions. 

Lodato63  has  studied  the  alterations  in  the  retina  which 
occur  after  excision  of  the  superior  cervical  ganglion, 
his  investigations  being  confined  to  dogs  and  rabbits, 

60.  Med.   Centralbl.,   1871,   Nr.   11. 

61.  Boll.  d.  It.  Acad.  di  Roma,  vol.  xix,  1892-93,  p.  240. 

62.  Abst.,  Zeit.  f.   Augenheilk.,   1899,  1,  p.   89. 

63.  Abst.  Annal.  d'Oculist.,  cxxvi,  1901,  p.  229. 
3 


34 

and  has  found  that  after  ahlatiou  of  the  ganglion 
changes  occur  which  are  localized  exclusively  in  the 
retinal  ganglion  cells.  These  lesions  are  slight  and  com- 
pletely repair  themselves  in  the  rabbit;  in  the  dog  they 
are  graver  and  last  longer.  With  regard  to  the  optic 
nerve,  he  believes  that  the  degenerated  fibers  which 
have  been  found  after  extirpation  are  not  really  of  a 
sympathetic  nature,  but  are  fibers  which  have  been  de- 
generated owing  to  alterations  in  the  ganglion  cells  of 
the  retina. 

It  will  be  remembered  that  Angelucci  thought  that 
the  enophthalmos  was  due  to  an  actual  smallness  of  the 
globe,  that  is,  to  an  atrophy  of  it ;  indeed,  he  maintained 
that  after  sympathetic  section  or  gangliectomy  a  form 
of  micro phthalmos  developed.  This  change  Hertel  in 
his  later  experiments  on  young  rabbits  was  unable  to 
demonstrate.  Levinsohn,53  referring  to  trophic  changes 
after  gangliectomy,  found  that  the  weight  of  the  eyes 
was  about  the  same  on  the  operated  and  the  non-operated 
sides.  Indeed,  there  were  no  very  constant  alterations, 
the  surest  one  being  a  greater  filling  of  the  choroidal 
vessels  on  the  operated  side,  and  the  anterior  part  of 
the  eye  seemed  smaller  on  this  side.  The  sphincter  in 
all  cases  where  the  sympathetic  ganglion  was  removed, 
or  the  capital  branches  cut,  was  longer  and  narrower 
than  on  the  other  side;  where  the  sympathetic  was  re- 
sected, the  sphincter  was  shortened.  Gatti64  finds  that 
osmosis  at  the  lens  does  not  alter  for  a  time  (three  to 
fifteen  days)  after  section  of  the  sympathetic,  but  fre- 
quently loss  of  weight  is  evident. 

The  relation  of  the  ciliary  ganglion  to  trophic  changes 
and  the  experiments  of  Bernheimer,  Marina  and  others, 
and  the  idea  of  Grosz  on  the  etiology  of  neuroparalytic 
keratitis,  have  been  described.05  Curiously  enough,  mam 
years  ago,  the  relation  of  the  cervical  sympathetic  to 
neuroparalytic  ophthalmia  was  studied  by  Sinitzin,  who 
thought  the  cornea  on  the  sympathectomized  side  was 
more  resisting  than  that  on  the  non-operated  side  to 
foreign  substances,  for  example,  bits  of  glass,  inasmuch 
as  on  the  normal  side  corneal  ulceration  always  occurred 
under  these  circumstances,  but  not  in  the  other  eye.  If  the 
trigeminus  was  cut  in  the  cranium,  the  neuroparalytic 

64.  Abst.   Jahresb.    f.   Ophthal..    1898,   p.   272. 

65.  Bach   thinks   that   Bernheimer's  cauterization   of   the   cornea 
produced  changes  in  the  iris  and  ciliary  body  which  were  responsible 
for  the  degeneration  set  up  in  the  ciliary  ganglion. 


phenomena  did  not  appear  in  the  eye  if  not  long  before 
this  operation,,  or  shortly  afterwards,  the  upper  cervical 
sympathetic  was  excised.  He  believed  that  the  increased 
filling  of  the  blood  vessels  caused  by  the  operation,  and 
on  that  account  the  elevation  of  temperature,  played 
the  important  role  of  inhibitory  agents. 

9.  Claude  Bernard,  Brown- Sequard  and  others  be- 
lieved that  the  cervical  sympathetic  had  an  influence  on 
the  shape  of  the  cornea  and  described  flattening  of  this 
structure  after  sympathectomy.  Heese,  however,  was 
unable  to  find  any  alteration  in  the  cornea  and  lens 
under  these  circumstances,  and  doubted  whether  the 
sympathetic  had  an  inhibitory  action  on  accommodation ; 
in  fact,  according  to  him,  it  takes  no  part  in  the  process 
at  all.  Eulenberg  and  Guttman39  believed  that  the  my- 
osis  was  accompanied  with  myopia,  which  in  its  turn 
was  dependent  on  a  spastic  state  of  the  accommodation, 
but  Nicati  in  his  cases  of  palsy  of  the  sympathetic  was 
unable  to  find  any  effect  which  this  lesion  could  have 
upon  visual  acuity,  nor  was  he  ever  able  to  discover  any 
influence  on  accommodation,  and  he  disputes  the  con- 
tention of  Eulenberg  and  Guttman  that  myopia  ought 
to  be  a  consequence  of  paralytic  myosis.  A  detailed 
reference  to  the  influence  of  the  sympathetic  on  accom- 
modation, and  therefore  on  refraction  in  general,  has 
been  given  and  the  subject  need  not  further  be  discussed. 

Before  finally  leaving  the  subject  of  the  ocular  phe- 
nomena which  follow  section  of  the  cervical  sympathetic 
or  extirpation  of  its  ganglia,  reference  should  be  made 
to  the  interesting  observations  of  Dupm^.66  This  experi- 
menter found  that  ptosis,  retraction  of  the  globe,  ad- 
vancement of  the  nictitating  membrane  and  myosis  after 
section  of  the  cervical  sympathetic  all  disappear  if  the 
restiform  body  is  punctured  on  the  side  corresponding 
to  that  on  which  the  lesion  in  the  sympathetic  has  been 
established.  In  other  words,  puncture  of  the  restiform 
body  produces  just  the  opposite  effects  of  destruction  of 
the  sympathetic,  and  these  effects,  moreover,  can  be 
transmitted  in  animals  from  one  generation  to  another, 
or,  as  Dupuy  expresses  it,  transmitted  through  heredity. 

X.    EFFECT   OF   DRUGS   AND   TOXIC    AGENTS    ON   THE    SYM- 
PATHETIC. 

The  scope  of  the  present  paper  and  the  time  at  my 
disposal  do  not  permit  more  than  a  very  brief  reference 

66.  Compt.  rend,  de  la  Soc.  de  Biol.,  vol.  Jubilaire,  1899,  p.  246. 


3C 

to  this  very  interesting  subject.  Eeference  may  first  be 
made  to  the  exceedingly  interesting  work  of  Langley  on 
the  influence  of  nicotin  on  the  activity  of  ganglionic 
nerve  cells.67  He  found  that  in  certain  animals,  for 
example,  the  rabbit,  cat  and  dog,  after  nicotin  injections 
into  a  vein,  electrical  stimulation  of  the  cervical  sym- 
pathetic on  the  proximal  side  of  the  superior  cervical 
ganglion  failed  to  produce  any  secretion  of  saliva;  nor 
was  he  able  to  induce  secretion  under  these  circum- 
stances if  the  electrode  was  applied  to  the  ganglion 
itself.  On  the  other  hand,  if  the  electrical  stimulus 
was  applied  to  the  nerve  fibers  between  the  ganglion  and 
the  gland,  active  secretion  was  at  once  established.  The 
natural  inference  from  this  experiment  is  that  the  nico- 
tin interferes  with  the  passage  of  secretory  impulses, 
and  that  this  interference  is  in  the  ganglion  cells  them- 
selves. He  further  established  his  position  by  painting 
the  superior  cervical  sympathetic  ganglion  with  nicotin 
and  again  checked  the  passage  of  the  secretory 
impulses,  but  when  the  nerve  coat  itself  was  painted 
instead  of  the  ganglion,  no  interference  in  the  stimuli 
occurred. 

Pursuing,  his  studies  still  further,  Langley  proved 
that  when  an  animal  was  under  the  influence  of  nicotin, 
the  cells  of  the  ciliary  ganglion  were  so  affected  that  they 
formed,  to  use  the  technical  expression,  a  "fault"  in 
the  transmission  of  the  impulses  to  the  sphincter  of  the 
iris,  and  in  the  same  manner  a  fault  in  the  transmis- 
sion of  the  dilator  impulses  was  obtained.  In  brief, 
Langley's  experiments  proved  that  nerve  impulses, 
whether  they  be  motor  to  striped  or  unstriped  muscle, 
secretory,  vasomotor  or  inhibitory,  were  all  arrested  in 
a  nicotinized  animal,  provided  these  impulses  were 
obliged  to  traverse  ganglion  cells.  This  important  ob- 
servation of  Langley  has  been  much  used  in  physio- 
logic experiments,  and  it  is  the  custom  now  of  this  dis- 
tinguished experimenter,  as  well  as  others  who  have  fol- 
lowed in  his  footsteps,  to  utilize  nicotin  in  the  manner 
already  described  if  they  wish  to  ascertain  if  impulses 
pass  along  nerve  fibers  directly  or  only  by  synapse 
through  the  cells  of  a  ganglion.  If  impulses  such  as 
have  been  described  fail  to  pass  in  a  nicotinized  animal, 
it  is  quite  certain  that  ganglion  cells  are  in  the  path,  and 
form,  to  use  the  expression  previously  used,  a  fault. 

67.  Trans.  Royal  Soc.  and  Jour,  of  Physiology. 


37 

We  are  especially  indebted  to  Walter  Jessop08  for  inter- 
esting observations  on  the  action  of  cocain  on 
the  sympathetic.  Shortly  after  the  discovery  of 
this  alkaloid,  he  noted  the  enlargement  of  the  pal- 
pebral  fissure  and  the  apparent  prominence  of  the  eye 
which  followed  instillation  in  the  conjunctival  cul-de- 
sac  of  solutions  of  cocain,  and  satisfied  himself  by  a 
series  of  experiments,  which  have  often  since  been  con- 
firmed, that  this  widening  of  the  palpebral  aperture 
was  due  to  a  stimulating  or  irritating  action  of  the 
drug  on  the  sympathetically-supplied  unstriped  muscu- 
lar fiber  of  the  lids,  to  which  reference  has  so  frequently 
been  made  in  this  paper.  If  cocain  in  4  per  cent,  so- 
lution is  instilled  into  the  conjunctival  cul-de-sac,  as 
we  all  know,  the  pupil  dilates.  This  dilated  pupil  will 
respond  to  strong  light  stimulus  and  to  accommodation, 
is  neutralized  by  eserin  or  pilocarpin,  and  still  further 
widens  under  the  influence  of  atropin.  Xumerous  ex- 
perimenters, notably  Jessop,  Limbourg  and  others, 
have  shown  that  this  mydriasis  can  not  be  due  to  par- 
alysis of  the  peripheral  endings  of  the  oculomotor  nerve, 
because  the  mydriasis  is  larger  than  that  after  section  of 
the  third  nerve.  Moreover,  the  pupil  acts  to  light  and 
to  accommodation,  and  pilocarpin,  which  acts  alone  on 
the  nerve  endings  of  the  oculomotor,  produces  myosis. 
Neither  does  the  drug  paralyze  the  sphincter  of  the 
pupil  because  the  action  to  light  and  accommodation 
is  retained,  and  eserin,  which  directly  stimulates  the 
muscular  fibers,  causes  contraction.  Finally,  it  has  been 
noted  that  the  mydriasis  produced  by  irritation  of  the 
sympathetic  is  exactly  like  that  which  follows  the  in- 
stillation of  cocain,  and  therefore  it  has  been  reasoned, 
on  good  grounds,  it  would  seem,  that  cocain-dilatation 
of  the  pupil  is  due  to  a  stimulant  action  of  the  drug  on 
the  mydriatic  nerve  endings,  that  is  to  sa}',  on  the  sym- 
pathetic. 

The  physiologic  action  of  the  mydriatic  alkaloids,  es- 
pecially of  those  which  belong  to  the  series  of  tropins, 
is  of  great  interest,  but  only  a  brief  reference  can  be 
made  to  them  in  so  far  as  their  action  on  the  sympa- 
thetic nerve  is  concerned.69  The  dilatation  of  the 

68.  Trans.  Ophth.  Soc.  U.  K.,  vol.  v,  1885,  p.  240  ;  Ibid.,  vol.  vi. 
1886,  p.  123. 

69.  Those  interested   in   this  subject   may   consult   H.    C.    Wood. 
Therapeutics.    Its   Principles   and   Practice,    eleventh   edition,    1900. 
pp.    175-177 ;    H.    C.    Wood,    Jr.,    The    Physiologic    Action    of    the 
Mydriatic  Alkaloids,  THE  JOURNAL  of  the  A.  M.  A.,  Feb.  21,  1903. 


38 

pupil  caused  by  atropin  is  not  centric  in  its  origin, 
but  depends  on  a  peripheral  action  of  the  drug. 
Numerous  experiments  and  the  character  of  the  myd- 
riasis  have  led  to  the  belief  that  the  dilatation  is  due 
to  palsy  of  the  oculomotor  endings  and  at  the  same 
time  to  a  stimulant  action  of  the  drug  on  the  sympa- 
thetic nerve  fibers,  or  perhaps  to  a  general  paralysis  of 
the  unstriped  pupillary  muscle. 

Although  it  is  usually  stated,  and  it  seems  to  me 
with  entire  accuracy,  that  the  myosis  which  is  produced 
by  the  instillation  of  eserin  is  due  to  a  stimulant  action 
of  this  drug  on  the  muscular  fiber,  some  distinguished 
authorities,  notably  H.  C.  Wood,  believe  that  the  drug 
paralyzes  the  peripheral  sympathetic  nerve  endings  in 
the  iris,  although  we  know  when  there  is  complete 
paralysis  of  these  nerve  endings  after  gangliectomy 
or  sympathectomy,  eserin  still  further  contracts  the 
pupil,  which  would  at  least  strongly  indicate  that  this 
action  is  not  on  nerves,  but  on  muscle  fiber  itself. 

Eecent  experiments  by  S.  J.  Meltzer  and  Clara  Melt- 
zer70  on  the  relation  of  the  innervation  of  an  organ  to 
the  influence  of  suprarenal  extract  on  it,  have  developed 
some  interesting  facts.  It  is  well  known  that  intraven- 
ous injections  of  suprarenal  capsule  cause  dilatation  of 
the  pupil,  which  lasts  a  very  short  time — less  than  a 
minute.  Now  the  Drs.  Meltzer  have  observed  that  when 
the  sympathetic  is  cut  a  subcutaneous  injection  of 
adrenalin  causes  a  dilatation  of  the  pupil  on  the  oper- 
ated side  which  can  last  an  hour  and  longer,  and  still 
further  noted  as  remarkable  that  this  effect  does  not 
take  place  if  the  injection  is  tried  on  the  day  of  the 
operation.  Ordinarily,  instillation  of  this  drug  in  the 
conjunctival  sac  produces  no  effect  on  the  pupil,  but 
when  the  sympathetic  is  cut,  its  instillation  will  cause 
a  dilatation  of  the  pupil  lasting  for  some  time.  In  other 
words,  .this  substance  exerts,  ordinarily  at  least,  no  ef- 
fect on  a  normal  organ,  in  this  instance  the  iris,  but  does 
exert  a  very  considerable  effect,  and  of  long  duration,  if 
this  tissue  is  deprived  of  some  portion  of  its  nervous 
control.  Later  experiments  by  Dr.  S.  J.  Meltzer71  are 
interesting  as  showing  a  difference  in  the  effect  be- 
tween the  removal  of  the  sympathetic  ganglion  and  sim- 
ple section  of  the  cervical  sympathetic  nerve.  Subcu- 

70.  American  Medicine,  Feb.  7,  1903. 

71.  Personal   communication.   March   16.   1903. 


39 

taneous  injection  of  adrenalin,  or  instillation  into  the 
conjunctival  sac,  causes  a  dilatation  of  the  pupil  on  the 
side  where  the  ganglion  is  removed,  and  not  on  the  side 
where  the  sympathetic  has  been  cut,  the  ganglion  re- 
maining intact — again  an  interesting  confirmation  of 
work  which  has  several  times  been  referred  to  in  this 
paper  of  a  difference  in  the  effects  of  gangliectomy  and 
sympathectomy,  differences  which  may  be  well  taken 
into  consideration  when  the  surgical  side  of  the  ques- 
tion is  considered. 

CONCLUSIONS. 

From  this  review  of  the  literature  and  the  various 
opinions  of  the  authors  which  have  been  quoted,  the  fol- 
lowing conclusions  may  be  drawn: 

1.  Although  lachrymal  secretion  may  be  caused  by 
excitation  of  the  sympathetic,  and  increased  lachryma- 
tion  by  section  of  the  cervical  sympathetic  or  removal 
of  the  superior  cervical  ganglion,  the  sympathetic  itself 
should  not  be  considered  the  nerve  of  secretion  for  the 
lachrymal  gland. 

2.  Dilatation  of  the  pupil  is  probably  caused  by  contrac- 
tion of  a  set  of  radially  arranged  muscular  or  contractile 
fibers,  the  so-called  dilatator  pupillas,  which  is  supplied  by 
the  sympathetic,  and  by  inhibition  of  the  sphincter  of  the 
iris.  The  dilating  impulse  transmitted  to  the  iris  passes 
through  the  cervical  sympathetic  and  in  general  terms 
along  the  mydriatic  tract  of  the  pupil,  which  proceeds 
from  a  center  in  the  medulla  as  far  as  the  second 
dorsal  nerve,  follows  its  communicating  branch  to  the 
cervical  sympathetic,  and  arrives  at  the  internal  carotid 
plexus,  from  which  point  it  passes  to  the  nasociliary 
branches  of  the  nasal  nerve,  which  as  the  long  ciliary 
nerves  supply  the  muscular  tissue  of  the  iris. 

3.  Although  experimental  and  clinical  evidence  favors 
the  presence  of  a  center  situated  between  the  spinal 
cord  and  the  exits  of  the  sixth  cervical  and  fourth  dor- 
sal nerves,  to  which  Budge  relegated  the  origin  of  the 
pupil-dilating  fibers  of  the  sympathetic,  its  existence 
has  not  been  definitely  proven. 

4.  Although  the  nature  of  the  ciliary  ganglion  has 
not  been  positively  determined  in  any  one  species  of 
animal,   and,   although  it  differs  greatly   in   different 
species,  the  weight  of  evidence  is  in  favor  of  the  gang- 
lion belonging  to  the  sympathetic  system,  at  least  in  so 
far  as  man  is  concerned.    The  root  fibers  which  belong 


40 

to  the  oculomotor  end  in  the  ciliary  ganglion,  where  a 
new  neuron  begins  for  the  fibers  which  pass  to  the 
ciliary  muscle  and  the  sphincter  of  the  pupil,  i.  e.,  the 
oculomotor  does  not  act  directly  on  the  sphincter  of 
the  pupil,  but  only  in  association  with  the  ciliary  gang- 
lion. There  is  a  certain  amount  of  evidence  that  this 
ganglion  is  related  to  the  pupil  movements  in  the  form 
of  a  center,  and  it  probably  contains  cells  which  are 
active  in  the  sensibility  of  the  cornea,  but  lesions  of  the 
ganglion  itself,  although  they  have  been  considered  by 
Grosz  to  be  the  basal  cause  of  true  neuroparalytic  kera- 
titis,  have  not  been  proved  to  sustain  this  position  by 
experiments,  inasmuch  as  trophic  changes  have  not  been 
observed  after  extirpation  of  the  ganglion.  Removal  of 
the  ganglion  has  little  or  no  influence  on  intraocular 
tension,  and  its  excision  is  not  a  rational  procedure  for 
the  relief  of  glaucoma. 

5.  There  is  no  satisfying  evidence  that  the  sympathetic 
is  related  to  the  function  of  accommodation,  and  it  has 
not  been  proved  that  the  sympathetic  has  any  power  in 
causing  negative  accommodation,  nor  has  it  been  demon- 
strated that  alterations  in  refraction  noted  after  stimu- 
lation of  the  sympathetic  are  due  to  actual  change  in 
the  lens. 

6.  Electrical  stimulation  of  the  cervical  sympathetic 
produces  at  first  an  increase  and  later  a  decrease  of  in- 
traocular tension,  the  increase  being  probably  due  to  an 
effect  on  the  vessels  of  the  eye.     Slow-acting,  mechanic- 
ally produced  irritation  of  the  sympathetic  causes  a  ris<- 
of  tension,  which,  according  to  Lodato,  is  independent 
of  dilatation  or  constriction  of  the  blood  vessels,  and 
also  independent  of  the  state  of  the  pupil.      Section  of 
the  sympathetic,  or  extirpation  of  the  sympathetic  gang- 
lion, is  followed  by  a  fall  of  intraocular  tension,  which 
probably  depends  on  vascular  and,  perhaps,  muscular 
changes.    The  lowering  of  tension  is  more  decided  after 
excision-of  the  ganglion  than  after  section  of  the  sym- 
pathetic cords,  but  in  either  case  the  effect  is  a  tem- 
porary one,  and  may  not  last  more  than  a  few  days,  and 
sometimes  disappears  within  a  few  hours. 

7.  Electrical  stimulation  of  the  cervical  sympathetic- 
produces  on  the  side  stimulated  a  dilatation  of  the  pupil 
as  a  result  of  contraction  of  the  dilatator  pupillas,  as- 
sociated, perhaps,  with  an  inhibition  of  the  sphincter. 
At  the  same  time  there  may  occur  on  the  opposite  side 


'•  41 

a  contraction  of  the  pupil,  which  either  depends  on  the 
consensual  pupil  reflex,  or  represents  a  reflex  trans- 
mitted through  the  sympathetic  fibers  joining  the 
cranial  nerves  in  the  region  of  the  cavernous  sinus. 

8.  Electrical  stimulation  of  the  cervical  sympathetic 
causes  retraction  of  the  nictitating  membrane  and  prop- 
tosis,  owing  to  the  action  transmitted  to  the  unstriped 
muscular  fiber.     In  contrast  to  the  general  rule,  irrita- 
tion of  the  sympathetic  in  rabbits  causes  a  retraction  of 
the  eyeball  in  the  orbit,  which  has  been  attributed  by 
Heese  to  a  contraction  of  the  orbital  vessels  and  the  ane- 
mia which  this  causes. 

9.  Electrical  stimulation  of  the  cervical  sympathetic 
is  followed  by  contraction  of  the  blood  vessels  of  the 
conjunctiva  and  of  the  iris,  and  perhaps  by  alteration'  in 
the  caliber  of  the  vessels  of  the  retina,  although  observa- 
tions  on  the   last-named   phenomenon   have   been    ex- 
tremely contradictory. 

10.  Stimulation  of  certain  areas  of  the  brain  cortex 
causes  dilatation  of  the  pupil,  associated,  if  the  cervica] 
sympathetics  are  intact,  with  all  the  symptoms  of  stim- 
ulation of  the  cervical  sympathetic.     Division  of  the 
sympathetic  stops  the  other  symptoms,  but  not  the  di- 
latation of  the  pupil  which  is  supposed  to  be  due  to  in- 
hibition of  the  tonic  action  of  the  third  nerve   (Par- 
sons). 

11.  Sympathectomy  or  gangliectomy  causes  the  fol- 
lowing effects:     Myosis,   narrowing  of    the    palpebral 
aperture,  projection  of  the  nictitating  membrane,  re- 
traction of  the  globe  of  the  eye,  hyperemia  of  the  vessels 
of  the  conjunctiva,  increased  lachrymal  secretion,  dim- 
inished intraocular    tension,    certain    ophthalmoscopic 
and  microscopic  lesions  in  the  eyeground,  and  possibly 
trophic  disturbances. 

12.  The  symptoms  of  sympathetic  section  or  paralysis 
lessen  after  a  time,  myosis  being  the  most  permanent, 
lasting  sometimes  for  'years.    The  degree  of  permanence, 
however,  of  the  paralytic  phenomena  varies  much  in  dif- 
ferent animals. 

13.  Myosis  is  greater  after  excision  of  the  cervical 
sympathetic  ganglion  than  after   section   of   the   sym- 
pathetic cord,  because  it  is  probable  that  a  certain  tone 
is  exercised  by  the  ganglion ;  that  is,  that  it  has  a  differ- 
ent, and,  as  it  was,  a  stronger  action  on  the  eye  than 
the  nerve  trunk  itself  (Levinsohn). 

14.  All  the  phenomena  of  paralysis  of  the    sympa- 


42 

thetic  nerve,  especially  the  contraction  of  the  pupil, 
which  follow  extirpation  of  the  superior  cervical  gang- 
lion gradually  become  less  marked  and  may  disappear 
or  even  give  place  to  the  opposite  condition,  especially  if 
the  animal  is  anesthetized  or  subjected  to  sensory  or  emo- 
tional stimuli.  In  other  words,  extirpation  of  the  upper 
cervical  ganglion  causes  the  symptoms  of  sympathetic 
paralysis  which  may  disappear  and  give  place  to  the 
signs  of  sympathetic  excitation.  Such  paradoxical  pu- 
pillary dilatation  may  depend  on  degenerative  processes 
in  the  post-cellular  nerves  of  the  ganglion  (Langen- 
dorff). 

15.  The  my  otic  pupil,  which  follows  sympathectomy 
or  gangliectomy,  responds  to  light    stimulus,   is  still 
further  contracted  by  eserin,  and  may  be  dilated  by 
atropin.     It  is  uninfluenced  by  cocain,  which,  however, 
may  exercise  its  influence  in  widening  the  contracted 
palpebral  fissure. 

16.  A  considerable  excision  of  the  sympathetic  must 
be  made  in  order  to  prevent  a  rapid  regeneration. 

17.  Narrowing  of  the  palpebral  fissure,  ptosis  sympa- 
thica,  and  enophthalmos  are  probably  due  to  relaxation 
of  Miiller's  muscle,  aided,  perhaps,  by  atrophy  of  the 
orbital  fat.     It  has  not  been  proved,  although  it  has 
been  asserted,  that  there  is  an  actual  reduction  in  the 
size  of  the  globe,  that  is,  a  true  microphthalmos,  under 
these  circumstances. 

18.  Sympathectomy  or  gangliectomy  may  cause    in- 
creased vascularization  of  the  eyeground,  perhaps  hem- 
orrhages in  the  ciliary  body  and  ciliary  processes,  and 
alteration  in  the  retinal  ganglion  cells. 

19.  Puncture  of  the  restiform  body  produces  just  the 
opposite    effects    of    destruction    of  the    sympathetic 
(Dupuy). 

20.  Nicotin  paralyzes  the  activity  of  ganglionic  nerve 
cells  in  the  sympathetic.     Cocain  dilates  the  pupil  by 
stimukting  the  mydriatic  nerve  endings  in  the  iris. 
Atropin  dilates  the  pupil,  partly  by  a  paralytic  action  on 
the  oculomotor  endings  of  the  sphincter,  and,  perhaps, 
by  a  stimulant  action  on  the  sympathetic  nerve  fibers, 
or  more  likely,  by  causing  a  general  paralysis  of  the 
unstriped  pupillary  muscle.     Instillations  of  adrenalin, 
ordinarily  inactive  in  causing  dilatation  of  the  pupil, 
become    exceedingly    active    when    the    sympathetic    is 
cut  or  the  ganglion  removed,  and  cause  under  these 
circumstances  marked  dilatation  of  the  pupil. 


THE    INFLUENCE    OF    RESECTION    OF     THE 

CERVICAL  SYMPATHETIC  GANGLIA 

IN  GLAUCOMA. 


WILLIAM  H.  WILDER,  M.D. 

Assistant  Professor  of  Ophthalmology,  Rush  Medical  College,  Uni- 
versity   of    Chicago ;    Professor    of    Ophthalmology,    Chicago 
Policlinic;    Surgeon   to   the   Illinois   Charitable 
Eye  and  Ear  Infirmary. 

CHICAGO. 


This  paper  does  not  pretend  to  be  a  treatise  on  the 
subject  mentioned  in  the  title,  nor  does  it  assume  to 
give  any  positive  conclusions  as  to  the  value  of  the 
operation  of  sympathectomy  in  glaucoma ;  for  it  may  be 
said  at  the  outset  that,  despite  the  study  of  almost  all 
the  literature  on  the  subject  in  its  preparation  and  the 
collection  of  published  and  unpublished  data  in  this 
country,  I  feel  that  positive  conclusions  are  not  yet  to 
be  reached,  and  I  can  only  offer  this  as  a  contribution 
that  may  possibly  aid  in  future  work. 

I  wish  at  first  to  express  my  sincere  thanks  to  the 
ophthalmologists  of  the  country  who  so  generously  re- 
sponded to  the  letter  asking  for  data  concerning  cases 
of  excision  of  the  sympathetic  ganglia  for  glaucoma,  and 
for  the  latest  possible  reports  of  the  condition  of  such 
cases. 

In  this  way  it  has  been  possible  to  secure  records  of 
almost  all  the  cases  of  glaucoma  treated  by  this  means 
in  this  country.  In  several  instances  the  reports  seem 
so  favorable  that  one  is  tempted  to  draw  general  con- 
clusions, while  in  others  the  data  are  so  meager  or  the 
time  that  has  elapsed  since  the  operation  is  so  short 
that  positive  deductions  are  unwarrantable.  Such  re- 
ports would  be  more  valuable  if  in  every  instance  care- 
ful clinical  records  had  been  kept,  together  with  charts 
of  the  visual  fields.  Nothing  is  more  important  in  the 


44 

stud}'  of  chronic  glaucoma  than  the  condition  of  the 
peripheral  vision,  and  such  record  in  a  number  of  these 
cases  is  lacking. 

I  desire,  first,  to  present  a  detailed  report  of  seven 
cases  of  sympathectomy  for  glaucoma  in  my  own  prac- 
tice which  are  still  under  observation,  two  of  which  are 
rather  recent.  I  shall  then  give  an  abstract  of  the 
records  of  cases  of  sympathectomy  for  glaucoma  that 
have  been  done  in  this  country,  as  they  were  furnished  to 
me  by  the  observers  in  answer  to  the  circular  letter  sent 
out  this  spring.  Many  of  these  cases  have  already  been 
published,  but  the  observers  have  kindly  sent  me  the 
latest  possible  report  on  the  condition : 

CASE  1. — Chronic  inflammatory  glaucoma — right  eye.  Sym- 
pathectomy (no  benefit).  Iridectomy  (improvement). 

Felix  H.,  aged  40  years.  Entered  Illinois  Eye  and  Ear  In- 
firmary April  29,  1901.  Family  history  negative,  and  no 
previous  history  of  eye  trouble  until  April,  1898,  when  he 
lost  the  sight  of  the  left  eye  by  having  it  struck  with  a  piece 
of  hot  brass.  He  could  see  shadoAvs  with  it  until  one  year 
before  admission.  Some  three  weeks  after  the  injury  to  the 
left  eye,  the  right  became  inflamed,  and  he  states  that  he  was 
unable  to  see  with  it  for  two  or  three  weeks,  and  then  lie 
recovered  vision.  In  the  last  two  months  he  has  noticed 
failure  of  vision,  with  occasional  pain  in  the  right  eye.  Halos 
have  been  noticed  around  a  light.  On  admission  R.  E.  V.— 
20/50  with  Cyl.+l.oO,  180°,  slight  improvement.  Conjunctiva 
of  right  eye  injected  and  there  is  engorgement  of  the  ciliary 
vessels.  Pupil  moderately  dilated  and  vertically  oblong.  Re- 
sponds to  light.  T.+.  Optic  disc  distinctly  excavated,  but  no- 
pulsation  of  the  vessels.  L.  E.  V.=0.  Conjunctiva  injected; 
pupil  dilated,  cataract.  T.-j-L  ^o  perception  of  light.  Fun- 
dus  not  visible.  Eserin,  grains  ii-j$i,  was  used  three  times 
daily,  and  the  pupil  became  somewhat  smaller  and  the  ten- 
sion less.  For  visual  fields  see  Figure  1,  which  shows  marked 
contraction  in  all  meridians. 

May  16,  1901,  R.  V.=20/70  with  Cyl.+1.50,  180°,  through 
stenopf.ic  slit  20/50.  Severe  pain  last  night.  A.  c.  shallow.  T. 
+  1.  Pupil  dilated  5  mm.  In  the  afternoon  of  this  day,  under 
chloroform  narcosis,  Dr.  F.  C.  Schaefer  removed  the  right 
superior  cervical  sympathetic  ganglion.  Contraction  of  the 
pupil  immediately  followed,  but  tension  was  not  lowered  until 
several  hours  after  the  operation.  At  the  time  of  the  opera- 
tion there  was  neither  pallor  nor  flushing  of  the  face,  nor  wa- 
there  an  increase  of  lachrymal  secretion.  Ptosis  of  right  side 
was  noticed  after  recovery  of  consciousness. 

May  17,  1901.  Patient  comfortable,  right  pupil  contracted. 
T.  lower  than  before,  but  still  +. 


Figure  1,  Case  1. — Felix  H.,  aged  40.  Before  sympathectomy. 
Chronic  inflammatory  glaucoma.  April  29,  1901.  Rt.  eye 
V=20/50.  T.-K  Good  ilium,  obj.  1  cm.  sq. 


Figure  2,  Case  1. — Three  weeks  after  sympathectomy.  Chronic 
inflammatory  glaucoma.  June  17,  1901.  Rt.  eye  V— 20/40.  T.+ 
Good  ilium,  obj.  1  cm.  sq. 


46 

May  18,  1901.  Considerable  headache.  Pupil  contracted. 
T.+. 

May  20,  1901.  Considerable  pain  in  wound  anil  head.  T. 
slightly  +.  R.  V.  —20/40. 

There  was  some  infection  of  the  wound,  but  by  June  7  it 
had  completely  healed  and  patient  had  no  more  pain  and  also 
no  headache.  The  slight  improvement  in  central  vision  con- 
tinued at  20/40  and  the  tension  was  only  slightly  increased. 
The  fields,  however,  showed  no  improvement.  (Fig.  2.) 

June  13,  1901.  Vision  fell  to  20/70,  with  an  increase  of  ten- 
sion. This  was  not  controlled  by  eserin. 

June  20,  1901.  Tension  has  been  elevated  for  one  week  and 
there  has  been  occasional  pain  in  the  eye.  Large  iridectomy 
done  upward. 

June  22,  1901.    Very  slight  reaction  from  iridectomy. 

July  2,  1901.  R.  V.=20/100.  Tension  normal.  No  pain. 
Central  vision  began  to  improve,  but  occasionally  there  was 
slight  pain  in  the  eye  and  slightly  increased  tension. 

From  Aug.  2,  1901,  to  date  of  his  discharge,  Aug.  29,  1901, 
the  tension  remained  normal  and  the  eye  was  quiet.  R.  V. 
with  Cyl.+l.OO.  Ax.  20°=20/30+.  Visual  fields  were  un- 
changed. See  Figure  3. 

CASE  2. — Chronic  inflammatory  glaucoma.  Both  eyes.  Rt., 
sympathectomy  (marked  temporary  improvement).  Tridec- 
tomy. 

Edw.  L.  V.,  aged  62  years,  entered  Illinois  Eye  and  Ear 
Infirmary  June  29,  1901.  No  history  of  previous  eye  disease. 
History  of  rheumatism.  Father  became  blind  at  the  age  of 
70  years.  Examination  of  urine  shows  nothing  abnormal. 
About  five  years  before  patient  noticed  he  would  occasionally 
see  rings  of  color  around  a  light,  but  it  was  not  until  six 
months  before  admission  that  he  commenced  to  have  pain  in 
his  eyes,  which  he  describes  as  dull,  persistent  and  centering 
over  the  left  eye.  He  has  noticed  a  gradual  failure  of  vision, 
and  at  different  times  a  complete  loss  of  vision  in  different 
fields.  There  is  a  history  of  an  acute  exacerbation  three  weeks 
ago,  since  which  time  he  has  had  more  trouble.  Patient  hy- 
peropic.  R.  E.  V.  with  Sph.+5. 00=20/1 00+1. 

Cornea  clear,  not  anesthetic.  A.  c.  shallow.  Some  circum- 
corneaj.  injection.  Pupil  not  dilated,  responds  feebly  to  light. 
T.+.  Lens  slightly  cloudy.  Disc  deeply  cupped  with  glau- 
coma halo. 

L.  E.  V.  with  Sph.+5.00  =  Fingers  at  5  feet  in  temporal  field. 
Pupil  normal  in  size.  T.+.  Some  opacity  of  crystalline  lens. 
Disc  deeply  cupped.  For  fields  of  right  eye  see  Figure  4.  It 
was  impossible  to  chart  the  field  of  vision  of  the  left  eye. 
Eserin,  grains  ii-3i,  t.  i.  d.,  was  used  in  each  eye. 

Operation  July  12,  1901.  Under  ether  narcosis  the  right 
superior  cervical  sympathetic  ganglion  was  removed  by  Dr.  F. 


Figure    3,    Case    1. — Five    weeks  •  after    iridectomy.      Chronic    in- 
flammatory glaucoma.     Aug.   L'9,   1901.     Kt.  eye  V=20/30-K     T.   n. 


Hiyllt. 


Figure   4,    Case    2. — Edw.    V.,    aged    62.      Chronic    inflammatory 
glaucoma.     June  29,  1901.    Rt.  eye  V=20/100.     T.+.    Obj.  1  cm.  sq. 


Figure  5,  Case  2. — Eighteen  days  after  sympathectomy.  Chronic 
inflammatory  glaucoma.  July  30,  1901.  Rt.  eye  V=20/40+.  T.  n. 
Obj.  1  cm.  sq. 


Figure  6,  Case  2. — One  month  after  sympathectomy.  Chronic 
Inflammatory  glaucoma.  Aug.  8,  1901.  Rt.  eye  V=20/30.  T.  n. 
Obj.  1  cm.  sq. 


49 

C.  Schaefer.  The  operation  was  successfully  and  easily  per- 
formed and  the  patient  bore  it  well.  Soon  after  the  opera- 
tion it  was  noticed  that  the  right  pupil  was  contracted,  there 
was  ptosis  and  the  tension  was  about  normal. 

July  10,  1901.  R.  V.  with  Sph. +5.00=20/50.  Pupil  small. 
T.+.  " 

July  17,  1901.  R.  V.  with  Sph. +5=20/70.  Pupil  small. 
T.+.  Wound  in  the  neck  healed  by  first  intention  and  pa- 
tient experienced  no  ill  effects  from  it.  Vision  began  to  im- 
prove, although  tension  remained  slightly  increased. 

July  30,  1901.  R.  V.  with  Sph.+5.00=20/40+.  Fields  in- 
creased (Fig.  5).  Tension  is  also  nearer  normal. 

Aug.  8.  1901.  R.V.  with  Sph.+5.00=20/30.  Tension 
normal.  Field  (Fig.  6). 

Aug.  31,  1901.  He  left  the  hospital  against  my  advice. 
T.  n.  R.  V.=20/30.  Field  as  above. 

Oct.  26,  1901.  Readmitted  to  the  hospital.  R.V.  with  glass 
=20/70.  L.  V.  with  glass=Fingers  6  in.  Tension  of  right 
eye  decidedly  plus.  The  impairment  of  central  vision  is  prob- 
ably due  to  increasing  cloudiness  of  the  central  portion  of  lens. 
The  left  lens  was  much  more  opaque  than  when  he  left  the 
house  in  August.  The  visual  fields  of  the  right  eye  had  be- 
come markedly  contracted,  as  seen  in  Figure  7.  As  the  ten- 
sion remained  high  I  did  an  iridectomy  on  the  right  eye 
Nov.  14,  1901,  followed  one  week  later  by  an  iridectomy  of  the 
left  eye.  Although  the  operation  was  easily  performed  and 
without  accident  or  complication,  it  had  the  effect  of  causing 
the  opacity  of  the  lens  to  increase  more  rapidly.  The  tension 
returned  to  normal  and  patient  left  the  hospital  Dec.  6,  1901. 
R.  V.=l 5/200.  L.  V.=shadows.  He  promised  to  return  as 
soon  as  the  cataract  in  the  right  eye  made  him  helpless,  but 
although  I  have  endeavored  to  find  him,  I  have  not  seen  him 
since. 

CASE  3. — Simple  glaucoma,  both  eyes.  Left  sympathectomy, 
without  benefit.  Left  iridectomy,  with  questionable  benefit. 

Dr.  John  H.,  aged  46  years,  consulted  me  Nov.  15,  1901,  re- 
ferred by  Dr.  A.  E.  Prince,  Springfield,  111.  General  health 
good.  At  the  age  of  20  he  had  granulated  eyelids,  from  which 
he  suffered  for  two  years,  recovering  completely.  No  trouble 
of  eyes  since  that  time  until  January,  1901,  when  his  eyesight 
began  to  grow  dim,  and  he  would  occasionally  see  halos  around 
a  light  with  the  left  eye.  These  attacks  of  dimness  of  vision, 
during  which  he  seemed  to  be  looking  through  a  "fog  or  haze," 
came  on  at  intervals  of  five  or  six  days,  and  lasted  several 
hours.  There  was  no  pain,  redness  of  tenderness  of  the  eyes 
during  these  attacks  or  during  the  intervals.  He  noticed  that 
his  sight  was  usually  clearer  in  the  morning  than  in  the 
afternoon.  Four  weeks  before  coming  to  me  he  consulted  Dr. 
Thompson  of  Indianapolis,  who  pronounced  his  case  glau- 
4 


Figure  7,  Case  2. — Fourteen  weeks  after  sympathectomy.  Chronic 
inflammatory  glaucoma.  Oct.  26,  1901.  Rt.  eye  V=20/70.  T.+l. 
Obj.  1  cm.  sq. 


'.'•  '  \ 


Figure  8,  Case  3. — Dr.  J.  H.,  aged  46.     Simple  glaucoma.     NOT. 
16,  1901.     Rt.  eye  V— 20/200.     T.+l.     Obj.  1  cm.  sq. 


51 

coma  and  prescribed  cserin,  which  he  was  using  at  the  time. 
Condition  at  time  of  first  examination,  Nov.  15,  1901:  R.  V. 
with  Sph.+2.00~Cyl.— 3.50,  180°:=20/200.  L.  V.  with  Sph. 
+4.003Cyl.+3.00  75°— 20/200.  He  was  wearing  such  lenses 
constantly.  Both  pupils  small  and  somewhat  irregular  and  do 
not  respond  to  light.  Tension  of  each  +1. 

On  discontinuing  the  use  of  the  eserin  for  one  day  the  pupils 
dilated  moderately  so  that  the  fundus  could  be  seen  clearly. 
There  was  a  deep  glaucomatous  excavation  in  each  disc.  The 
•  fields  (Figs.  8  and  9),  taken  Nov.  1C,  1901,  showed  marked 
contraction  in  the  nasal  region,  that  of  the  right  noticeably 
so.  The  anterior  chamber  was  about  of  normal  depth.  After 
discussing  the  question  of  operation  with  the  patient  it  was 
decided  to  do  a  sympathcctomy  on  the  left  side.  Nov.  20r 
1001,  the  left  superior  cervical  sympathetic  ganglion  was  ex- 
cised by  Dr.  Schaefer  at  the  Post-Graduate  Hospital  under 
chloroform  narcosis.  The  operation  was  successfully  per- 
formed. Immediately  after  the  operation  the  left  pupil, 
which  had  been  without  eserin  for  two  days  and  was  mod- 
erately dilated,  contracted,  and  the  tension  became  normal. 
The  patient  recovered  nicely  from  the  operation,  but  had  some 
sensitiveness  of  the  left  side  of  the  neck  and  face  and  inabil- 
ity to  raise  the  left  arm  and  shoulder.  He  was  also  quite- 
hoarse,  and  this  symptom  persisted. 

Dec.  1,  1901.  L.  V.  with  Sph.+4.00~Cyl.+3.00  75°=20/200. 
T.  n.,  pupil  small,  ptosis  of  left.  Fields  show  no  increase. 
R.  V.  with  Sph.+2.00~Cyl.— 3.50,  180°=r20/200.  Pupil  small, 
from  pilocarpin.  T.  n.,  sometimes  +. 

Dec.  30,  1901.  Condition  same  as  on  December  1.  Color 
fields  slightly  enlarged  (Fig.  10).  He  left  the  city  Avith  in-, 
structions  to  continue  the  miotic  and  to  report  at  once  if  his- 
sight  began  to  get  worse. 

Feb.  12,  1902.  Patient  returned  with  the  statement  that 
his  sight  was  failing.  R.  V.  with  glass=10/200.  L.  V.  with 
glass=8/200.  Pupils  moderately  contracted.  T.+.  Fields- 
of  left  contracted,  as  shown  in  Figure  11. 

Feb.  14,  1902.  Broad  iridectomy  upward  in  left  eye.  The 
eye  made  a  good  recovery  from  the  operation. 

Feb.  24,  1902.  R.  V.  with  glass=15/200.  T.  n.  L.  V.  with 
glass=6/200.  T. — .  Patient  is  somewhat  hoarse  and  has  im- 
perfect power  of  the  left  shoulder.  He  left  Chicago  for  hi* 
home  in  southern  Illinois.  He  continued  the  use  of  pilocarpin^ 
grs.  ii-5i. 

A  letter  from  him  written  April  19,  1903,  tells  me  that  he 
has  R.  V.  with  glass=13/200.  L.  V.  with  glass=9/200.  The 
left  vision,  however,  seems  to  be  somewhat  brighter  than  the 
right.  He  says  the  fields  are  limited  upward  and  downward, 
but  fairly  good  to  the  temporal  side.  The  tension  in  ea<  li  eye- 
is  plus,  that  of  the  right  being  a  little  higher  than  the  Mt. 


Figure   9,    Case    3. — Before    sympathectomy.      Simple    glaucoma. 
Nov.  16,  1901.     Left  eye  V=20/200.     T.+l.     Obj.  1  cm.  sq. 


Figure  10,  Case  3. — Five  weeks  after  sympathectomy.  Simple 
glaucoma.  Dec.  30,  1901.  Left  eye  V==20/200.  T.  n.  Obj.  1 
cm.  sq. 


Figure  11,  Case  3. — Three  months  after  sympathectomy.     Simple 
glaucoma.     Feb.  12,  1002.     Left  eye  V=8/200.     T.+.     Obj.  1  cm.  sq. 


Figure   12,   Case  4. — Christian   K.,   aged  74.      Simple  glaucoma. 
Oct.  7,  1902.     Rt.  eye  V=20/70.     T.+.  Obj.  1  cm.  sq. 


54 

He  says  he  never  has  the  least  pain  or  trouble  in  any  way  in 
the  eyes  and  his  condition  is  such  that  he  "can  get  around 
with  comparative  comfort,"  and  attend  to  his  duties  as  post- 
master, a  position  he  obtained  after  giving  up  his  practice. 
His  voice  is  hoarse  and  weak,  and  his  neck  in  front  of  the  scar 
is  sensitive. 

CASE  4. — Right,  simple  glaucoma.  Left,  absolute  glaucoma. 
Right,  sympathectomy  (improvement). 

Christian  K.,  aged  74,  admitted  to  Illinois  Eye  and  Ear  In- 
firmary Oct.  3,  1902.  One  year  before,  he  had  severe  pain  in 
the  left  eye,  which  lasted  two  weeks,  and  which  was  pro- 
nounced neuralgia  by  one  physician  who  saw  him,  and  another 
said  his  impaired  vision  was  due  to  a  developing  cataract. 
Halos  were  noticed  around  a  light  and  the  eye  was  consid- 
erably reddened.  The  sight  was  very  imperfect  after  this 
period  of  painfulness,  but  the  eye  quieted  down.  Eight  months 
later  he  had  a  most  severe  attack  of  pain  in  the  left  eye, 
which  lasted  two  or  three  hours,  after  which  he  discovered 
that  the  eye  was  completely  blind.  This  attack  was  pro- 
nounced neuralgia  by  the  physician  who  saw  him  after  it  was 
over.  Soon  after  this  experience  he  noticed  a  fogginess  of  the 
vision  of  the  right  eye,  more  marked  at  times  than  at  others. 
Halos  were  occasional!}7  seen  around  lights,  but  he  had  very 
little  or  no  pain  in  the  eye.  He  is  a  strong,  healthy  man  with 
110  history  of  previous  disease.  Urine  normal. 

On  admission  R.  V.=20/70.  Emmetropia.  L.  V.=0.  Right 
«ye  T.+  (?).  A.  c.  of  normal  depth,  pupil  not  dilated,  and 
responds  to  light  and  ace.  Optic  disc  not  markedly  cupped, 
but  of  a  grayish  unhealthy  appearance  with  indistinct  margin, 
sucn  as  is  seen  in  incipient  glaucoma. 

Left  eye,  T.+3.  Marked  pericorneal  injection.  Pupil  mod- 
erately dilated  and  shows  a  greenish  reflex.  Fundus  invisible. 
Diagnosis:  right,  simple  glaucoma;  left,  absolute  glaucoma. 
Eserin,  grain  i-^i,  twice  daily  for  each  eye.  The  first  chart 
of  visual  fields  taken  a  few  days  after  his  admission  is  seen 
in  Figure  12.  This  was  not  taken  by  myself,  and  may  be 
somewhat  inaccurate,  for  the  next  field,  Figure  13,  taken  on 
Oct.  15.  1902,  after  several  days'  use  of  eserin,  shows  a  con- 
siderably increased  field :  but  as  the  central  vision  had  im- 
proved to  20/40  from  20/70,  and  the  tension  had  become 
normal  after  the  use  of  the  miotic,  the  improvement  in  the 
fields  may  probably  be  ascribed  to  the  treatment.  All  the 
other  fields  wrere  taken  carefully  by  myself. 

Oct.  20,  1902.  Excision  of  the  right  superior  cervical  sym- 
pathetic ganglion  was  made  by  Dr.  F.  C.  Schaefer,  without  any 
difficulty.  Pupil  became  small  immediately  after  the  opera- 
tion and  tension  became  reduced.  Ptosis  followed,  but  there 
was  no  pain  about  the  face  or  neck  and  no  congestion  of  the 
•conjunctiva  or  skin.  Patient  made  an  excellent  recovery 


ftiff/it 


Figure   13.    C'ase   4. — After  1    week   of  eserin.      Simple  glaucoma. 
Oct.  15.  1902.     Rt.  eye  V=  20/40.      T.  n.     Obj.  1  cm.  sq. 


Figure    14,    Case   4. — Two    weeks   after    sympathectomy.      Simple 
glaucoma.     Nov.  5,  1902.     Rt.  eye  V=20/40.     T.  n.    Obj.  1  cm.  sq. 


Riglu. 


Eye 


Figure  13,  Case  4. — Eight  weeks  after  sympathectomy.  Simple 
glaucoma.  Dec.  17,  1902.  Rt.  eye  V=20/40+2.  T.  n.  Obj.  1 
cm.  sq. 


H,glit 


Eye 


Figure   16,   Case  4. — Six   months  after  sympathectomy.     Simple 
glaucoma.     April  20,  1903.     Rt.  eye  V=20/40+.     T.  n.  Obj.  1  cm.  sq. 


from  the  operation  with  no  unfavorable  symptoms.  Slight 
ptosis  of  the  right  eye  was  noticed. 

Oct.  28,  1902.     Pupil  contracted.     T.  n.     R.  V.=20,  40. 

Nov.  5,  1902.  Fields  show  a  remarkable  improvement.  fSee 
Fig.  14.)  R.  V.  20/40.  T.  n. 

Dec.  17,  1902.  Improvement  continues.  Fields  almost 
normal  (Fig.  15).  R.  V.=20/40+2.  Patient  still  has  some 
pain  in  right  side  of  face  and  jaw,  as  well  as  the  right  auricle. 

Jan.  14,  1903.  Left  the  hospital  to-day.  R.  V.— 20/40+2. 
T.  n.  Pupil  contracted.  Field  same  as  above. 

April  18,  1903.  Readmitted.  In  left  eye  there  has  been 
severe  inflammation  and  ulceration  of  the  cornea,  which  be- 
gan two  or  three  weeks  ago.  R.  V.=20/40+.  Pupil  still  con- 
tracted and  T.  n.  Fields  normal  (Fig.  16).  It  will  probably 
be  necessary  to  enucleate  the  left  eye. 

CASE  5.— Simple  glaucoma  left  eye.  Sympathectomy.  Dis- 
ease stationary. 

J.  S.,  aged  76  years.  First  consulted  me  Nov.  12,  1902,  com- 
plaining that  for  weeks  previously  he  had  the  sensation  of  a 
fog  being  over  the  left  eye.  He  had  also  noticed  halos  around 
a  light  at  night.  This  phenomenon  of  colored  rings  he  had 
noticed  at  times  for  years,  but  he  remembered  that  at  such 
times  there  was  usually  a  slight  secretion  from  the  lids.  He 
also  experienced  at  times  a  dull  pain  in  the  left  eye,  and  the 
same  but  less  frequently  in  the  right.  He  -stated  that  at  one 
time  he  had  severe  neuralgic  pains  extending  from  the  bridge 
of  the  nose  backward  around  the  left  orbit  to  the  ear.  General 
health  good,  except  that  he  had  at  times  indistinct  rheumatic 
pains  and  suffered  from  a  bladder  disturbance,  probably  on  ac- 
count of  prostatic  enlargement.  He  wears  glasses.  R.  Sph.  +  1.50 
with  Cyl.+l.OO,  Ax.  15°.  L.  Sph.+1.75  for  distance,  and  R. 
Sph.+5.00~Cyl.+1.00,  Ax.  15°.  L.  Sph.+o.OO  for  reading 
prescribed  by  an  ophthalmologist  a  year  or  so  before.  R.  V. 
=20/100  with  glass,  20/30+.  L.  V.=25/70  with  glass,  20/30. 
Right  tension  normal.  Left  tension  slightly  plus,  pupil  con- 
tracted with  miotic,  anterior  chamber  of  normal  depth,  optic 
disc  shows  glaueomatous  excavation,  that  of  the  right  is 
normal.  The  chart  of  the  right  fields  (Fig.  17)  shows  slightly 
contracted  color  fields.  That  of  the  left  (Fig.  18)  shows  a 
scotoma  in  the  upper  nasal  quadrant.  Pilocarpin,  grs.  ii-^i, 
t.  i.  d.,  was  ordered. 

Dec.  1,  1902.  Tension  has  remained  about  the  same  as  be- 
fore under  the  use  of  pilocarpin.  Pupil  remains  small  and 
anterior  chamber  of  good  depth.  L.  V.  with  glass=20'30. 
Left  fields  show  somewhat  more  contraction  in  the  upper  nasal 
quadrant.  (Fig.  19.) 

Dec.  2,  1902.  At  a  consultation  with  Dr.  Hotz  it  was  de- 
cided to  advise  an  operation.  As  the  anterior  chamber  was  of 
normal  depth,  and  the  fields  have  not  improved  under  the  con- 


Figure  17.  Case  5. — J.  S.,   aged   76.    Simple  glaucoma.     Nov    12 
1902.     Rt.  eye  V=20/30+.     T.  n.     Obj.  lem.  sq. 


Figure    18.    Case    5. — Simple    Glaucoma.      Nov.    13.    1902.      Left 
eye  V=20/30.     T.+.     Obj.  1  cm.  sq. 


Figure  19.   Case  5. — Simple  glaucoma.      Dec.    1,   1902.      Left  eye 
V=20/30.     T.+.     Obj.  1  cm.  sq. 


Figure  20,  Case  5. — Twelve  days  after  sympathectomy.  Simple 
glaucoma.  Dec.  18,  1902.  Left  eye  V=20/20 — 2.  T.  n.  Good  ilium. 
Obj.  1  cm.  sq. 


GO 

tinued  use  of  a  miotic,  although  the  pupil  was  markedly  con- 
tracted, it  was  thought  that  sympathectomy  offered  as  good  a 
chance  of  checking  the  glaucoma  as  iridectomy.  The  subject 
was  thoroughly  discussed  with  the  patient  and  his  family,  and 
it  was  finally  decided  to  try  first  the  operation  on  the  neck. 

Dec.  6,  1902.  Under  chloroform  narcosis  the  left  superior 
cervical  sympathetic  ganglion  was  excised  by  Dr.  Schaefer  in 
the  usual  manner.  The  pupil,  which  for  the  last  few  days  had 
recovered  from  the  influence  of  the  miotic,  contracted  promptly 
after  the  removal  of  the  ganglion.  There  were  no  accidents 
or  difficulties  accompanying  the  operation  and  the  patient 
recovered  well  from  the  anesthetic.  He  had  complete 
aphonia,  and  marked  hoarseness  continued  for  more  than  a 
week.  There  was  suffusion  of  the  left  eye  and  some  conges- 
tion of  the  conjunctiva,  mucous  membrane  of  the  left  side  of 
the  nose  and  skin  of  left  side  of  the  face  lasting  for  a  couple 
of  days.  Ptosis  of  the  left  side  was  also  noted.  The  patient 
was  also  confused  mentally  and  at  times  had  mild  hallucina- 
tions and  did  not  remember  where  he  was.  This  rather  alarm- 
ing symptom  continued  for  about  one  week,  and  gradually  dis- 
appeared. There  was  tendei-ness  about  the  angle  of  the  jaw 
and  some  pain  in  masticating.  Tension  remained  normal  with- 
out miotic.  Wound  healed  by  first  intention. 

Dec.  18,  1902.  Hoarseness  has  disappeared.  Ptosis.  Gen- 
eral condition  good.  L.  V.  Avith  glass=20/20 — 2.  T.  n.  Field 
not  markedly  changed  except  that  it  seemed  slightly  incrai-cii 
in  the  upper  nasal  quadrant  for  white,  and  slightly  decreased 
for  green  in  the  lower  temporal  area  (Fig.  20). 

The  patient  went  to  his  home  in  an  adjoining  state  soon 
after  this  date,  with  instructions  to  use  pilocarpin  regularly. 

Jan.  21,  1903.  Reported  to  me  again  on  this  date.  Refrac- 
tion has  changed  somewhat,  for  now  he  sees  best  with  Sph.-f- 
1.25  Cyl.+0.50,  180°,  which  gives  him  L.  V.=20/30.  Pupil  small. 
Tension  slightly  plus.  Field  was  taken  in  a  poor  light  as  com- 
pared with  the  others,  and  shows  more  contraction,  especially 
for  colors,  and  a  notch  appears  in  the  upper  temporal  field 
(Fig.  21).  He  still  has  some  pain  at  corner  of  left  jaw  when 
he  eats.  Slight  ptosis. 

CASE  C^ — Simple  glaucoma,  left.  Absolute  glaucoma,  right. 
Sympathectomy,  left  (improvement). 

Margaret  T.,  aged  78,  entered  the  service  of  Dr.  Beard  in 
Illinois  Eye  and  Ear  Infirmary  Jan.  25,  1903,  and  was  kindly 
referred  to  me.  Strong,  well-preserved  woman,  who  has 
usually  had  good  health,  except  that  since  childhood  she  has 
had  frequent  attacks  of  sick  headache,  which  continued  up  to 
two  years  ago,  when  the  sight  of  her  right  eye  began  to  fail, 
followed  soon  after  by  failing  vision  of  the  left.  Early  in  the 
course  of  the  disease  she  noticed  halos  around  a  light.  On 
admission,  R.  V.=perception  of  light  in  temporal  field.  T.+. 


Figure  21,  Case  5. — Six  weeks  after  sympathectomy.  Simple 
glaucoma.  Jan.  21,  1903.  Left  eye  V=20/30.  T.+  ( ?) .  Poor 
ilium.  Obj.  1  cm.  sq. 


Figure  22,  Case  6. — Margaret  T.,  aged  78.  Before  sympathec- 
tomy. Simple  glaucoma.  Jan.  30,  1903.  Left  eye  V=8/200. 
T.-K  Obj.  1  cm.  sq. 


A.  c.  of  normal  depth,  pupil  slightly  dilated,  spicules  of 
opacity  in  the  periphery  of  the  lens.  Optic  disc  sharply 
cupped,  with  atrophy  and  glaucomatous  halo.  L.  V.=8/200 
with  Sph.+3.50,  slight  improvement.  T.+.  A.  c.  of  normal 
depth,  pupil  slightly  dilated,  faint  spicules  of  opacity  in 
periphery  of  lens;  well  marked,  but  rather  shallow  excavation 
of  optic  disc  with  halo.  Eetinal  veins  somewhat  engorged. 
Disc  rather  pale.  No  pulsation  of  arteries  or  veins.  Patient 
is  hyperopic  and  has  been  wearing  Sph.+3.25  for  distance. 
She  has  marked  arteriosclerosis,  the  superficial  arteries  being 
very  hard.  Urinalysis  shows  specific  gravity  1024  albumin 
and  no  casts.  The  visual  fields  of  the  left  eye  (Fig.  22)  are 
markedly  contracted,  especially  the  color  fields,  and  the  nasal 
side  is  almost  obliterated.  Fields  of  right  eye  could  not  be 
charted.  Under  eserin  and  pilocarpin  the  tension  was  reduced 
to  nearly  normal  and  the  pupils  contracted. 

Feb.  14,  1903.    Left  pupil  considerably  dilated  5  mm.     T.+. 

Feb.  16,  1903.  Excision  of  left  superior  cervical  sympa- 
thetic ganglion  by  Dr.  A.  E.  Halstead  under  morphia  and 
chloroform  narcosis.  The  operation  was  uneventful  and  im- 
mediately after  the  removal  of  the  ganglion  the  left  pupil  con- 
tracted. 

Feb.  17,  1903.  T.  n.,  slight  ptosis  left,  pupil  contracted. 
Has  headache  and  is  hoarse. 

Feb.  19,  1903.  Pupil  again  somewhat  dilated,  but  not  so 
much  as  before  the  operation.  It  was  suspected  that  two  days 
before  the  operation  some  atropin  had  been  put  into  the  eye 
accidentally  by  the  use  of  an  atropin  dropper  when  the  eserin 
was  being  instilled  and  that  this  accounted  for  the  sudden 
mydriasis.  Immediately  after  the  operation  the  pupil  con- 
tracted for  24  hours,  then  dilated  for  a  few  days,  and  then 
again  contracted  and  remained  so.  Headache  persists  and 
there  is  anesthesia  of  the  left  auricle. 

Feb.  26,  1903.  Ptosis  of  left.  Pupil  y2  mm.  smaller  than 
the  right.  T.  n.  L.  V.=13/200. 

March  10,  1903.  L.  V.=13/200  with  Sph.+3.50=20/200. 
T.  n.  Pupil  remains  smaller  than  right.  Hoarseness  and 
headache  have  disappeared  and  sensation  has  returned  to  left 
ear. 

March  30,  1903.  L.  V.=18/200  with  Sph.+ 3.50=207 120. 
T.  n.  Tvight  pupil  3%  mm.,  left  pupil  3  mm.  Ptosis  persists. 
Fields  improved  (Fig.  23). 

April  15,  1903.  Left  hospital  with  instructions  to  use  pil- 
ocarpin and  to  return  at  once  if  vision  begins  to  fail. 

June  1,  1903.  Readmitted  to  hospital.  L.  V.  with  Sph. 
+3.50=20/200.  T.  n.  Left  pupil  smaller  than  right.  Fields 
about  the  same  as  in  Figure  23. 

CASE  7. — Simple  glaucoma,  left;  simple  absolute  glaucoma, 
right.  Left  sympathectomy  ( without  benefit ) .  Left  iridec- 


v- 


Figure  23,  Case  6.— Six  weeks  after  sympathectomy.  Simple 
glaucoma.  March  30,  1903.  Left  eye  V=20/200.  T.  n.  Obj. 
1  cm.  sq. 


Figure  24,  Case  7. — Chas.  D..  aged  57.  Before  sympatbectomy. 
Simple  glaucoma.  Feb.  10,  1903.  Left  eye  V=r20/40.  T.+  Obj. 
1  cm.  sq. 


tomy,    complicated    with    intraocular    hemorrhage.      Loss    of 
sight. 

Chas.  F.  D.,  aged  57,  was  admitted  to  the  Illinois  Eye  and 
Ear  Infirmary  Feb.  10,  1903,  where  he  was  assigned  to  the 
service  of  Dr.  Chas.  H.  Beard,  who  kindly  transferred  him  to 
my  service.  Patient  usually  had  good  health  and  excellent 
sight  until  two  years  before,  when  he  first  noticed  that  the 
vision  of  the  right  eye  was  foggy  at  times,  and  he  would  see 
halos  around  a  light.  The  right  vision  continued  to  fail,  but 
he  had  no  pain  or  inflammation  in  it.  Three  months  before 
his  admission  the  same  trouble  began  in  his  left  eye,  so  that 


Kl/K 


Figure  25,  Case  7. — One  month  after  sympathectomy.  Simple 
glaucoma.  March  13,  1903.  Left  eye  V=20/40.  T.+l.  Obj.  1 
cm.  sq. 

he  cd*uld  no  longer  see  well  to  do  the  fine  work  that  his  occu- 
pation, that  of  bronze  sculpture  work,  required.  Three  weeks 
before  entrance  to  the  hospital  he  first  noticed  halos  about  a 
light  with  the  left  eye.  He  states  that  he  has  had  occasional 
attacks  of  temporary  blindness  in  both  eyes,  lasting  a  few 
minutes.  Urine  normal.  Arterial  tension  rather  high.  R.  V. 
perception  of  light.  T.+.  No  fields.  Media  somewhat  hazy. 
Optic  disc  deeply  cupped.  L.V.=20/100  with  Sph.+1.50= 
•20/40,  pupil  responsive  to  light  and  moderately  dilated,  a.  c. 


Go 


normal  in  depth.  T.+-  Glaucomatous  excavation  of  optic 
disc.  Fields  markedly. contracted,  only  a  small  temporal  field 
remaining  (Fig.  24). 

Feb.  16,  1903.  Removal  of  left  superior  cervical  sympathetic 
ganglion  under  morphia-chloroform  narcosis  by  Dr.  A.  E. 
Halstead.  The  operation  was  somewhat  difficult  on  account 
of  the  patient's  thick  neck.  The  ganglion  was  very  small,  but 


Figure    26. — Section    of    ganglion    from    Case    4.       Pigmented, 
irregular  cells  with  excentric  nuclei. 


was  removed  with  about  3  cm.  of  the  nerve.  Spinal  accessory 
nerve  was  cut  and  was  afterward  united  with  catgut  suture. 

Feb.  17,  1903.  Patient  recovered  well  from  the  operation. 
Pupil  is  contracted,  ptosis  marked.  Partial  anesthesia  of  left 
side  of  face  and  neck.  T.+  as  before. 

Feb.  26,  1903.  L.  upper  lid  droops  about  2  mm.  more  than 
5 


66 

right.  Right  pupil  4  mm.  L.  pupil  21X>  mm.  L.  V.  with 
Sph.+ 1.50=20/40.  T.+.  Pain  in  left  side  of  face  and  jaw, 
slight  hoarseness  and  some  loss  of  power  in  left  shoulder. 
The  hyperesthesia  of  the  left  side  of  the  face  about  the  jaw 
and  ear  was  intense,  so  that  he  could  not  bear  the  slightest 
touch.  Eserin  was  used  regularly. 

March    13,     1003.      L.  V.    with    Sph.+ 1.50=20/40.      T.+l. 


S?*ft4M 

m 


j 


Figure   27. — Section   of  ganglion    from   Case   5,    showing   marked 
vascularity. 

Ptosis  and  miosis  persist.  Hyperesthesia  of  the  face  gradu- 
ally getting  less.  Fields  much  contracted,  being  reduced  to  a 
narrow  slit  (Fig.  25). 

March   17,   1903.     Anterior  sclerotomy.     Slight  reduction  of 
tension. 


March  21,  1903.  Tension  again  as  high  as  before.  Under 
cocain  and  holocain  anesthesia  an  iridectomy  Avas  done  up- 
ward. Immediately  after  completing  the  corneal  incision  the 
wound  gaped  widely  and  after  a  portion  of  the  iris  had  been 
excised  vitreous  began  to  present  in  the  wound  and  the  patient 
complained  of  intolerable  pain.  After  cutting  off  the  portion 
of  extruding  vitreous  the  lens  was  forced  into  the  wound  and 


Figure  28. — Section  of  ganglion  from  Case  G,  showing  pigmenta- 
tion of  the  cells  and  apparent  increase  of  connective  tissue. 


had  to  be  removed.  Then  followed  more  vitreous  and  a 
copious  hemorrhage,  the  patient  all  the  time  experiencing  great 
suffering.  The  bleeding  was  finally  checked  and  the  eye 
bandaged.  The  patient  was  given  an  opiate  and  put  to  bed, 
and  immediately  had  a  severe  chill. 

March  22,  1903.     Patient  was  fairly  well  and  not  suffering 
much.     In  the  gaping  corneal  wound  was  seen  a  clot  of  blood 


and  a  tissue  resembling  iris  or  choroid.  There  was  compara- 
tively little  reaction  after  the  operation.  The  wound  became 
smooth  by  the  separation  of  the  protruding  mass  and  the  blood 
in  the  anterior  chamber  was  absorbed.  At  the  present  time, 
April  20,  1903,  the  wound  has  healed.  Eye  sensitive  to 
touch.  T. — 2.  V.=0.  Sensitiveness  of  the  side  of  the  face 


Figure  29. — Section  from  ganglion  of  Case  7,  showing  irregularly 
shaped,  deeply  pigmented  cells. 

has  disappeared  and  the  patient  has  completely  regained  the 
power  of  the  arm  and  shoulder. 

The  excised  ganglia  in  the  last  four  cases  were  pre- 
pared by  Dr.  E.  V.  L.  Brown,  the  pathologist  of  the 
Illinois  Eye  and  Ear  Infirmary,  and  were  examined  by 


69 

him  and  also  by  Dr.  Sydney  Kuh,  professor  of  diseases 
of  the  nervous  system  at  the  Post-Graduate  Medical 
School.  To  these  gentlemen  I  am  indebted  for  the  notes 
on  the  histologic  appearances  of  the  specimens.  All  the 
specimens  were  hardened  in  5  per  cent,  formalin  and 
corrosive  acetic  solution  and  stained  with  toluidin  blue 
and  with  hematoxylin  and  eosin. 

In  all  of  the  specimens  there  was  increased  pigmenta- 
tion of  the  ganglion  cells.  In  Cases  4  and  5,  mast  cells 
were  seen.  In  Cases  4,  5  and  7  it  was  noted  that  the 
cells  were  not  round,  but  of  irregular  shapes  (Figs. 
26,  27,  29). 

In  one  case,  No.  6,  cells  slightly  vacuolated  were  ob- 
served. In  two  cases,  Nos.  4  and  5,  it  was  noted  that  the 
cells  showed  excentric  nuclei,  and  in  the  same  cases 
marked  vascularity  was  present  (Figs.  26-27.)  Some  of 
these  features,  especially  the  pigmentation  and  the  vascu- 
larity, are  shown  in  the  accompanying  photomicro- 
graphs. None  of  the  specimens  shows  conspicuous  in- 
crease of  connective  tissue,  as  has  been  noted  by  some 
other  observers,  although  Figure  28  at  the  place  where 
the  picture  was  taken  apparently  shows  it.  The  his- 
tologic examination  lacks  completeness,  as,  unfortun- 
ately, there  was  not  available  for  control  study  normal 
ganglia  from  individuals  of  the  same  age  as  the  pa- 
tients. As  the  pigment  in  the  ganglion  cells  is  normally 
increased  in  advancing  age,  it  can  not  be  said  that  these 
present  an  abnormality. 

REPORT   OF  61   ADDITIONAL   OPERATIONS   OF   EXCISION   OF 

SUPERIOR  CERVICAL  SYMPATHETIC   GANGLION 

FOR   GLAUCOMA. 

JAMES   MOORES  BALL.      THREE   CASES1  OF  GLAUCOMA.      FOUR 
OPERATIONS. 

No.  8. — Glaucoma  absolutum  rt.  Rt.  sympathectomy.  Im- 
provement. 

Man,  aged  36.  R.  V.=P.l.  L.  V.=20/70.  Pain  in  right  eye 
for  two  months.  Chronic  irritative  glaucoma.  Optic  disc 
cupped.  T.+3. 

Operation. — May  15,  1899.  Excision  rt.  sup.  cerv.  sympth. 
ganglion.  Tension  fell  to  +1,  ptosis.  Vision  increased  to 
fingers  at  3  ft.  Report  April  4,  1903,  pain  was  relieved  for 
one  year.  T.  +1. 

1.   X.  Y.   Med.   .Jour..   1890. 


70 

Nos.  9  AND  10. — Simple  glaucoma.  Both.  Bilateral  sym- 
pathectomy, slight  improvement. 

Woman,  aged  43.  R.V.=0.  T.+3.  L.  V.=P.l.  T.+3.  Dur- 
ation, two  years.  No  pain.  Optic  disc  cupped.  No  fields 
taken. 

Operation. — Left  sympathectomy,  June  15,  1899.  Lachryma- 
tion,  Ocular  congestion  and  contracted  pupil  of  same  side  fol- 
lowed. Ptosis.  Eighth  day  counted  fingers  4  ft.  June  30, 
loth  day,  F.  5  ft.  in  temporal  field.  T.  n. 

Operation. — July  16,  1899.  Right  sympathectomy.  Four  days 
later,  R.  V.  hand  movements.  L.  V.=F.  7  ft.  R.  T.  +1. 
L.  T.  +1.  Report  April  4,  1903.  Patient  became  blind  in 
November,  1899,  from  an  acute  attack  of  glaucoma,  left. 

No.  11. — Hemorrhagic  glaucoma.  Sympathectomy.  Tem- 
porary improvement.  Report  of  author  April  4,  1903,  that  he 
once  removed  the  sup.  cervical  sympathetic  ganglion  in  a  man 
26  years  old  for  relief  of  pain  in  hemorrhagic  glaucoma.  Re- 
lief of  pain  was  immediate  and  lasted  ten  months.  One  year 
after  operation  the  man  had  his  eye  removed.  No  further  de- 
tails were  given. 

MELVILLE    BLACK.       ONE    CASE.       SUBACUTE    GLAUCOMA.1 

No.  12. — Sympathectomy.  Cure.  First  reported  October, 
1901,  Ophth.  Rec.  M.,  aged  35.  Colored.  Left  eye.  Duration 
-2  mos.  R.  V.=5/5.  L.  V.=F.  1  ft.  after  eserin  =5/20.  Left 
cornea  steamy  and  no  view  of  fundus  obtainable.  After 
eserin  pupil  was  so  small  that  fundus  could  not  be  seen.  Left 
T.+2,  pupil  dilated.  Fields  normal  after  eserin. 

Operation. — Dec.  24,  1900.  Excision  of  left  superior  and 
middle  cervical  sympathetic  ganglia,  followed  by  immediate 
return  to  normal  vision,  normal  tension,  contracted  pupil  1% 
mm.  and  normal  fields.  Ptosis,  congestion  of  conjunctiva,  in- 
creased lacrymation  were  noted. 

Report  April  7,  1903.  L.  V.=5/6  with  Sph.+  l.OO.  R. 
pupil  4  mm.  L.  pupil  3  mm.  T.  n.  Fields  normal.  No  symp- 
toms of  return  of  glaucoma  nor  any  other  symptoms  of  incon- 
venience. Ptosis  scarcely  noticeable  and  the  conjunctival  in- 
jection had  disappeared.  Slightly  myopic  before  operation. 
Now  hyperopic  1  D.  No  complications  or  accidents  attending 
operation. 

CALLAN.       ONE    CASE.       BUPHTHALMUS.       SECONDABY    GLAUCOMA. 

No.  13. — Sympathectomy.  No  improvement.  M.,  aged  25 
years.  Highly  myopic.  R.  V.  with  Sph. — 20  Cyl. — 1.00, 
105°=20/200.  L.  V.  with  Sph.— 22.00=20/200.  History  of 
gradually  failing  sight.  Nystagmus.  Tension  plus  1  in  each. 
Marked  excavation  of  optic  discs. 

Operation. — May  26,  1902.     Excision  of  rt.  sup.  cerv.  sym- 

•2.  Ophthalmic  Record,  October,  1901. 


71 

pathetic  ganglion.  After  op.  R.  E.  T. — 1.  L.  E.  T.+l.  Both 
pupils  contracted.  No  ptosis,  congestion  of  face  or  other 
phenomena.  Xo  accidents  or  complications. 

Report  March  27,  1903  (by  letter).  "Tension  at  present 
time  +  1.  The  only  improvement  is  that  the  operated  eye  is 
not  so  prominent  and  possibly  the  nystagmus  not  so  marked. 
Tension,  pupil  and  vision  remain  the  same  as  before  the  opera- 
tion. The  cosmetic  effect  is  an  improvement." 

D.   II.   COOVER.      ONE  CASE.3 

Xo.  14. — Simple  glaucoma.  Both.  Rt.  sympathectomy; 
temporary  improvement. 

M.,  aged  65  years.  Failing  vision  for  one  year.  R.  V.=P.l 
in  temporal  field.  T.  +3.  Optic  disc  cupped.  L.  V.=20/200. 
T.+2.  Disc  cupped.  Fields  contracted.  Miotics  useless. 

Operation. — March   31,    1900.     Excision   of   right  sup.   cerv. 
sympath.  ganglion.     A  few  days  later  tension  somewhat  lower. 
R.  V.=5  ft.     Four  months  later  R.  V.  again  reduced  to  P.I. 
T.  +3.     L.  V.  had  fallen  from  20/200  to  5/200. 

COLEMAN    W.    CUTLER.      ONE    CASE.      RIGHT    CHRONIC    IRRITATIVE 
GLAUCOMA.       LEFT,    ABSOLUTE    GLAUCOMA.       RIGHT,    SYMPA- 
THECTOMY, GREAT  IMPROVEMENT.    PREVIOUS  IRIDECTOMY.4 

Xo.  15. — M.,  aged  56.  Duration  of  disease  8  years.  History 
of  attacks  of  pain,  cloudy  vision,  halos  and  failing  sight. 
Sclerotomy  in  1897.  Iridectomy  in  right  in  1898.  June  2,  1901, 
R.  E.  F.  3  ft.  T.  +V2  to  1.  L.  E.  V.  0.  T.  +2.  After  eserin 
R.  V  .=20/200+.  Pain  in  both  eyes.  Fields  contracted. 

Operation. — June  10,  1901.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion.  One  day  after  T. — %.  V.=20/30.  Slight 
ptosis,  some  dysphagia,  pain  in  right  side  of  head  and  face 
and  impaired  phonation.  Improvement  continued.  Fields  in- 
creased. May,  1902,  one  year  after,  R.  V.=20/30.  Fields  in- 
creased. Xo  signs  of  nerve  lesions  except  some  paresthesia 
of  side  of  face  and  neck  and  occasional  sharp  pain  in  temporo- 
maxillary  articulation. 

Last  report,  March  27,  1903,  by  letter.  Cutler  has  not  seen 
patient  since  Aug.  25,  1902,  but  thinks  if  results  had  not  been 
favorable  he  would  have  called. 

W.    A.    FISHER.      ONE    CASE.      CHRONIC    GLAUCOMA.      RIGHT    SYM- 
PATHECTOMY.     NO  IMPROVEMENT. 

Xo.  16. — F.,  aged  62.  Both  eyes  affected  for  two  years. 
R.  V.=12/200.  T.  n.  Pupil  somewhat  dilated.  Excavation 
of  optic  disc.  Fields  contracted. 

Operation. — June  8,  1899.  Excision  of  rt.  sup.  cerv.  sympath. 
ganglion.  Xo  accidents  or  complications.  Operation  negative 

3.  Phila.  Med.  Jour.,  March  16,  1900. 

4.  Annals  of  Surgery.   Phila..   September.  1902. 


72 

as  to  effect  on  lid,  conjunctiva,  tears,  respiratory  passages 
and  skin  of  face.  Negative  as  to  effect  on  vision.  Last  report 
April  4,  1900,  ten  months  after  operation,  R.  V.=4/200.  L.  V. 
=0.  No  effect  on  pupil  or  vision.  Fields  unchanged. 

HENRY     CRADLE.       ONE     CASE.        CHRONIC     GLAUCOMA.       PREVIOUS 
IRIDECTOMY.      SYMPATHECTOMY.       (STATIONARY). 

No.  17. — F.,  aged  33  years.  Both  eyes  affected,  left  for  a 
period  of  three  years.  Both  optic  discs  cupped.  R.  V.= 
20/40+.  Fields  normal  on  temporal  side,  contracted  above 
10°,  down  10°,  inward  15°.  Pupil  moderately  dilated  on  ac- 
count of  large  coloboma.  T.  +.  Two  iridectomies  had  been 
done,  one  30  months,  the  other  15  months  before,  both  having 
apparently  delayed  the  course  of  the  disease,  but  not  stopping 
it  entirely.  L.  V.=0.  No  report  of  this  eye. 

Operation. — March  13,  1900.  Excision  of  sup.  cerv.  sympth. 
ganglion  of  rt.  side.  No  accidents  or  complications.  After 
operation  T. —  and  is  normal  after  two  and  a  half  years. 
Pupil  distinctly  contracted  for  two  or  three  months,  and  two 
and  a  half  years  after  operation  it  is  as  it  was  before.  Cen- 
tral vision  unchanged,  20/40+.  Doubtful  enlargement  of 
fields  at  first,  but  practically  stationary  during  two  and  a 
half  .years.  After  operation  there  was  ptosis,  slight  conges- 
tion of  conjunctiva  and  skin  of  face.  These  all  receded  in  a 
few  months. 

E.    GBUENING.       TWO    CASES.      ONE    CHRONIC    GLAUCOMA     (BOTH). 
ONE  OPTIC   ATROPHY    (BOTH).      CASE   1,  PREVIOUS  IRIDEC- 
TOMY.       SYMPATHECTOMY.        SLIGHT    IMPROVEMENT.5 

No.  18. — M.,  aged  60  years.  Both  eyes  affected  with 
chronic  glaucoma  for  three  years.  R.  V.=F.  in  upper  tem- 
poral quadrant  at  2  ft.  T.  +1.  Field  in  upper  temporal 
quadrant.  Disc  deeply  cupped.  Coloboma  from  previous  iri- 
dectomy.  L.  V.=0.  T.+l.  Disc  deeply  cupped. 

Operation. — In  1901.  Removal  of  rt.  sup.  cerv.  sympath. 
ganglion.  There  was  no  change  in  pupil.  T.  n.  and  remained 
so  for  one  year  after  operation.  Patient  retained  same  central 
and  peripheral  vision  at  time  of  last  report,  one  year  after 
operation.  Ptosis.  Paralysis  of  recurrent  laryngeal  causing 
dysphonia  that  lasted  nine  months  and  then  disappeared. 

No.  Isfc — X/eft  sympathectomy.     No  improvement. 

M.,  aged  35.  Atrophy  of  both  optic  discs  of  two  years'  stand- 
ing. Both  optic  discs  white.  R.  V.=0.  L.  V.=20/30.  Fields 
of  left  contracted  to  10°  in  every  direction.  Tension  normal 
in  each. 

Operation. — 1902.  Removal  of  left  sup.  cerv.  sympath. 
ganglion.  As  a  result  of  the  operation  there  was  some  sinking 
of  the  eyeball,  and  also  paralysis  of  left  recurrent  laryngeal 

5.  Ophth.   Sec.  N.  Y.  Academy  of  Medicine.  November,   1901. 


73 

nerve.  Dysphonia  lasted  about  six  months,  although  the 
paralysis  of  the  recurrent  laryngeal  persisted.  Tension  ro 
mained  normal.  Left  vision  was  completely  lost  two  months 
after  the  operation. 

A.    B.    HALE.      ONE    CASE.      THREATENED   GLAUCOMA,   LEFT.      ABSO- 
LUTE   GLAUCOMA,    RIGHT.     LEFT    SYMPATHECTOMY. 

No.  20. — F.,  aged  48.  Total  loss  of  vision  of  right  eye 
after  two  iridectomies  had  been  done.  R.  V.=0.  T.+.  Deep 
excavation  of  optic  disc.  L.  V.  with  Sph.+ 1.00=6/5.  T.+  (  ? ; 
Optic  disc  normal.  Pupil  normal.  Fields  contracted  and 
wavering. 

Operation. — Dec.  15,  1902.  Excision  of  left  sup.  cerv. 
sympath.  ganglion.  After  operation  L.  V.  with  Sph.+  1.00= 
6/5.  T. — .  Pupil  small.  No  effect  on  lid,  conjunctiva,  lachry- 
mation,  skin.  Loss  of  sensation  on  lower  half  of  ear.  Last 
report  March  1,  1903.  Condition  as  above.  Fields  normal. 
T.  n.  Operation  was  done  to  ward  off  an  impending  attack 
of  glaucoma.  This  operation  was  preferred  because  the  right 
eye  had  been  lost  after  two  iridectomies. 

J.    G.    HUIZINGA.       TWO    CASES.       1,    CHRONIC    SIMPLE    GLAUCOMA, 
BOTH    EYES.      DOUBLE    SYMPATHECTOMY.       NO    IMPROVE- 
MENT.     2,    CHRONIC   INFLAMMATORY   GLAUCOMA, 
BOTH    EYES.       LEFT    SYMPATHECTOMY. 
NO    IMPROVEMENT. 

Nos.  21  AND  22. — M.,  aged  57.  Both  eyes  affected  for  17 
years.  R.  V.=P.l.  T.+l.  Fields  greatly  contracted.  L.  V. 
6/20.  T.  n.  Field  for  white  contracted,  being  almost  oblit- 
erated on  the  nasal  side;  65°  temporal  side,  10°  above,  40° 
below.  Color  fields  about  10°. 

Operation. — Oct.  14,  1898.  Excision  of  both  sup.  cerv. 
sympath,  ganglia.  Immediate  effects,  conjunctiva  injected, 
slight  increase  of  lachrymation.  Inspiration  difficult  from 
slight  edema  of  glottis.  Patient  quite  hoarse  for  several  weeks, 
but  fully  recovered.  No  material  change  in  vision  of  either 
eye.  T.  n.  and  remaining  so  one  year  afterward.  Pupils  that 
were  about  4  mm.  before  operation  contracted  slightly  after- 
ward, and  then  returned  to  the  usual  size.  One  year  after- 
ward there  was  no  change. 

No.  23. — M.,  aged  36.  Chronic  inflammatory  glaucoma  of 
both  eyes  of  several  years'  duration,  with  recurring  attacks. 
R.  V.=F.  3  ft.  T.+3.  Pupil  widely  dilated  because  of  atropin 
used  by  patient's  physician.  Fields  could  not  be  taken.  Optic 
discs  could  not  be  clearly  seen.  L.  V.=F.  3  ft.  T.  3.  Pupil 
same  as  right.  Fields  could  not  be  taken.  Disc  could  not  be 
seen. 

Operation. — January,  1902.  Excision  of  left  sup.  cerv. 
ganglion  and  at  the  same  time  iridectomy  on  each  eye.  Re- 
sult: Vision  became  worse  and  worse,  until  there  was  com- 


74 

plete  blindness.  Considerable  lachrymation  for  several  weeks 
after  operation.  One  year  after,  R.  V.  T.+l.  L.  T.+2.  No 
accidents  or  complications  from  the  sympathectomy. 

ARNOLD  KNAPP.    ONE  CASE.    CHRONIC  GLAUCOMA  WITH  ATROPHY, 

BOTH    EYES.       BILATERAL    SYMPATHECTOMY    AFTER 

RIGHT   IRIDECTOMY. 

Xos.  24  AND  25. — M.,  aged  20.  No  history  as  to  duration. 
R.  V.=16/200  after  successful  iridectomy.  Optic  disc  deeply 
cupped  and  atrophic.  L.  V.=12/200.  T.+2.  Disc  cupped  and 
atrophic.  Fields  contracted  to  10°  of  center. 

Operation. — June  10, 1902.  Excision  of  both  sup.  cerv.  sympath. 
ganglia.  Slight  drooping  of  both  upper  lids  followed.  Hoarse- 
ness that  lasted  several  weeks.  V.  improved  to  20/200  each. 
R.  T.  n.  L.,T.+  (?).  Fields  did  not  change. 

Last  report  March  18,  1903,  ten  months  after  operation. 
R.  V— 20/200.  T.  n.  L.  V.=12/200.  T.+.  Fields  same  as 
before. 

HARRY     LAMOTTE.       FOUR     CASES.       ACUTE     INFLAM.     GLAUCOMA 
( BOTH )  .       IRIDECTOMY,     RIGHT,    RECOVERY.        SYM- 
PATHECTOMY,   LEFT,    RECOVERY.6 

No.  2G. — M.,  aged  27.  Duration  of  disease  three  months. 
Acute  attacks  of  glaucoma  relieved  by  eserin.  Cupping  of 
discs.  R.  Y.=F.  6  ft.  Iridectomy.  Vision  improved  in  six 
weeks  to  20/50.  L.  V.=P.l.  T.+L  Field  not  taken. 

Operation. — March  25,  1901.  Excision  of  left  sup.  serv. 
sympath.  ganglion  and  connections.  Ptosis,  increased  lachry- 
mation and  injection  of  conjunctiva  followed.  Pupil  before 
operation  was  dilated.  After  operation  it  contracted.  T. 
became  normal. 

Last  report  July  10,  1902.  R.  V.=20/40.  T.  n.  Field  some- 
what contracted.  Pupil  contracted.  L.  V.=20/20.  T.  n. 
Field  normal.  Pupil  normal. 

CHRONIC     INFLAM.     GLAUCOMA'     (BOTH).        DOUBLE     SYMPATHEC- 
TOMY.      RECOVERY. 

Nos.  27  AND  28. — F.,  aged  38.  Duration  of  two  and  a  half 
years  during  which  time  she  had  occasional  attacks  of  severe 
pain,  increased  tension,  impaired  vision.  In  the  intervals  be- 
tween attacks  vision  approached  nearly  to  normal.  R.  V.= 
20/30.  L.  V .=20/40.  Slight  cupping  of  optic  discs.  Visual 
fields  were  not  taken. 

Operation. — May  1,  1901.  Excision  of  left  sup.  cerv.  sympath. 
ganglion.  Pupil  contracted  afterward  and  has  remained  so. 
Slight  ptosis  occurred,  but  no  other  manifestation  except  an- 

6.  Ophthalmic  Record,   Chicago,   October.  1902  ;  Denver  Medical 
Times.  March.   1903. 


esthe-jia  of  side  of  face  and  neck,  which  disappeared  after 
several  months.  L.  V.  before  operation  20/200.  Vision  re- 
turned to  20/20.  T.  n. 

Operation.— July  9,  1901.  Excision  of  rt.  sup.  cerv.  sympath. 
ganglion.  For  about  one  week  before  R.  V.  had  been  much  re- 
duced and  there  was  considerable  pain.  R.  V.=P.l.  T.+l. 
Optic  disc  cupped.  After  operation  vision  soon  returned  to 
normal.  T.  n.  Slight  ptosis,  increased  lachrymation,  pupil 
contracted,  pain  and  discomfort  disappeared. 

Last  report  Sept.  1,  1902.  R.  V— 20/20.  T.  n.  Some  con- 
traction of  fields.  L.  V.=20/20.  T.  n.  Contraction  of  fields 
to  402. 

SIMPLE    GLAUCOMA,    RIGHT.      BIGHT    SYMPATHECTOMY.       IMPROVE- 
MENT. 

Xo.  29. — M.,  aged  43.  Duration  of  disease  six  months. 
Had  been  treated  by  some  quack  doctor  who  had  been  giving 
atropin  for  iritis.  L.  V.=20/20.  Eye  normal.  R.  V.=F.  3  ft. 
T.+2.  Pupil  dilated.  Visual  fields  could  not  be  taken. 

Operation. — Jan.  24,  1902.  Excision  of  rt.  sup.  cerv.  sympath. 
ganglion.  Xo  unfavorable  signs.  Xo  ptosis,  conjunctiva  in- 
jected, lachrymation  increased.  T.  remained  +2,  pupil  con- 
tracted. Central  vision  improved. 

Last  report  March  23,  1903,  fourteen  months  after.  R.  V. 
=20/70.  T.+l.  Pupil  contracted.  Fields  concentrically  con- 
tracted. Degree  not  given. 

SIMPLE     GLAUCOMA,     RIGHT.       RIGHT     SYMPATHECTOMY.       DEATH 
FROM     SEPSIS. 

Xo.  30. — M.,  aged  40,  large,  healthy  soldier.  History  of 
impairment  of  vision  of  right  eye  for  one  year.  R.  V.=20/30. 
T.+l.  Pupil  dilated,  concentric  contraction  of  fields,  slight 
•excavation  of  right  disc.  L.  V.=20/20.  T.  n.  Pupil  normal, 
slight  contraction  of  fields. 

Operation. — Feb.  17,  1903.  Excision  of  rt.  sup.  cerv.  sympath. 
ganglion.  Patient  took  ether  badly  and  chloroform  was  substi- 
tuted. Just  before  the  nerve  was  excised  he  vomited  suddenly 
and  expulsively  and  some  of  the  vomit  fell  into  the  wound.  This 
was  cleansed  with  the  utmost  care,  but  in  spite  of  all  precau- 
tion infection  extended  to  the  deep  structures  of  the  neck, 
and  he  died  of  septic  pneumonia  on  the  fifteenth  day  after  the 
operation.  After  operation  T.+l.  Pupil  contracted.  Slight 
aphonia,  increased  lachrymation  and  injection  of  conjunctiva. 
Fields  were  not  taken. 

JOSEPH    MULLEN.      ONE    CASE.      CHRONIC    1NFLAM.    GLAUCOMA 
(BOTH).    PREVIOUS  IRIDECTOMY.    RT.  SYMPATHEC- 
TOMY.     TEMPORARY  IMPROVEMENT.7 

Xo.  31. — F.,  aged  48.  History  of  bilateral  iridectomy  23 
years  previously  for  acute  glaucoma.  Gradual  decrease  in 

7.  Amer.  Med.,  June,  1901. 


7G 

vision  since  that  time  with  occasional  acute  pains  in  eyes  aud 
head.  Severe  attack  at  the  time  she  was  first  seen  by  the 
operator.  R.  V.=F.  5  ft.  T.+2.  L.  V.==5/200.  T.+2. 'Both 
optic  discs  cupped.  Right  field  irregularly  contracted  to  20° 
above,  30°  temporal,  20°  nasal,  15°  below.  Left  field  concen- 
trically contracted  to  about  30°. 

Operation. — March  18,  1900.  Excision  of  right  sup.  cerv. 
sympath.  ganglion.  Increased  lachrymation.  Congestion  of 
conjunctiva  and  face.  Coloboma  prevented  accurate  state- 
ment as  to  pupils.  Tension  in  both  eyes  normal.  Pain  was 
relieved.  Fields  in  both  eyes  were  increased  by  as  much  as  10 
to  20  degrees  all  around,  the  improvement  being  more  marked 
in  the  right.  Central  vision  improved.  Degree  not  stated. 
Three  months  after  operation  improvement  was  lost  and  in- 
creased tension  and  pain  returned. 

Nine  months  later  R.  V.=15/20.  L.  V.=20/200.  Chart* 
showed  decrease  of  fields  nearly  to  same  degree  as  before 
operation,  with  left  field  very  irregular.  Last  report  April 
8,  1903.  R.  V.=20/100.  Field  as  before  operation.  L.  V. 
=20/70.  Field  larger  than  it  was  Dec.  18,  1900. 

W.    B.    MARPLE.      ONE    CASE.      CHRONIC    GLAUCOMA.       SYMPATHEC- 
TOMY.       NO    IMPROVEMENT.8 

No.  32. — Patient  who  had  ribbon-shaped  keratitis.  V.= 
10-15/200.  T.+l.  Pupil  partly  dilated. 

Operation. — August,  1902.  Excision  of  sup.  cerv.  sympath. 
ganglion.  After  operation  T.  became  normal  and  pupil  dimin- 
ished in  size.  Vision  unchanged.  Patient  has  been  under  ob- 
servation six  months. 

H.   R.   PRICE.      TWO   CASES.       SIMPLE   CHRONIC   GLAUCOMA    (BOTH) 
WITH   IIEMORRHAGIC  RETINITIS   AND  CHRONIC   NEPHRITIS. 
RIGHT    SYMPATHECTOMY.        IMPROVEMENT. 

No.  33. — M.,  aged  70.  Duration  of  disease  one  year. 
R.  V.=P.l.  Improved  under  eserin  to  20/200.  Pupil  dilated. 
Tension  variable  from  T.  n.  to  T.+3.  Fields  contracted,  espe- 
cially on  nasal  side.  Numerous  hemorrhages  in  the  macular 
region.  Deep  excavation  of  disc.  L.  V.=20/100.  T.  n.  Pupil 
normal.  Hemorrhages  as  in  the  right,  typical  glaucoma  cup- 
ping. Before  operation  R.  V.  =P.l. 

Operation. — May  26,  1902.  Excision  of  right  sup.  cerv. 
sympath.  ganglion.  Pupil  contracted,  slight  hyperemia  of 
conjunctiva  and  skin  of  face  same  side,  increased  lachryma- 
tion slight,  and  slight  ptosis.  Seven  days  after  operation  R.  V. 
=20/200  with  Sph.— 1D.=20/100.  Field  considerably  en- 
larged. 

Last    report    Oct.    3,    1902.      Five    months    after    operation 

8.  N.  Y.  Medical  Record,  May  10,  1902. 


77 

R.  V  .=20/100.  T.  n.,  pupil  contracted.  Patient  not  seen  later. 
Result  considered  favorable  in  view  of  the  hemorrhagic  condi- 
tion. 

SIMPLE    GLAUCOMA.     EIGHT    SYMPATHECTOMY.      HISTORY    INCOM- 
PLETE.      PREVIOUS    IRIDECTOMY    MARCH,    1902. 

Xo.  34. — M.,  aged  55.  Duration  of  disease  one  year.  Had 
iridectomy  done  March,  1902.  V.  B.=20/40,  declining  to 
20/70  with  rapid  loss  of  field.  Persistent  plus  tension.  Deep 
glaucoma  cupping. 

Operation. — Aug.  1,  1902.  Excision  of  right  sup.  cerv. 
sympath.  ganglion.  Tension  became  minus  and  ptosis,  hyper- 
emia  of  conjunctiva  and  face  were  noticed,  as  well  as  slightly 
increased  lachrymation.  Xo  other  phenomena  and  no  acci- 
dents. Patient  left  hospital  15  days  after  operation  and 
subsequent  history  was  not  obtained. 

R.    C.    REESE.     ONE    CASE.     CHROMIC    SIMPLE    GLAUCOMA     (BOTH). 
IRIDECTOMY  FIVE   YEARS   BEFORE.     RIGHT   SYMPATHEC- 
TOMY.       IMPROVEMENT. 

Xo.  35. — F.,  aged  58.  Duration  of  disease  six  years. 
R.  V.=F.  10  ft.,  not.  improved  with  lens.  T.+.  Pupil  shows 
coloboma.  Fields  contracted  considerably  at  nasal  side.  Deep 
glaucoma  cupping  of  disc.  L.  V.=0.  Pupil  and  disc  as  in  rt. 
Double  iridectomy  had  been  done  five  years  before,  and  ever 
since  that  time  she  had  used  eserin  occasionally  to  keep  the 
tension  down. 

Operation. — May  28,  1902.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion.  T. — .  No  increase  of  central  vision. 
Slight  ptosis  and  neuralgic  pains  in  the  left  side  of  face  and 
neck  that  lasted  for  two  months. 

Last  report  April  20,  1903,  nearly  one  year  after  operation. 
R.  V.:=F.  10  ft.  Fields  unchanged.  T. — .  Does  not  have  to 
use  a  miotic. 

E.    C.    RENAUD.       SIX    CASES     (FIVE    BILATERAL).       CHRONIC    IRRI- 
TATIVE  GLAUCOMA,    RIGHT.       RIGHT    SYMPATHEC- 
TOMY.     IMPROVEMENT.0 

Xo.  36. — F.,  aged  48.  Duration  ten  months.  R.  V.=: 
20/200.  T.+3.  Pupil  dilated  and  immovable.  Media  hazy, 
disc  cupped.  Fields  not  taken.  L.  V.=20/20.  T.  n.  Pupil 
and  fundus  normal.  Attacks  of  pain  in  right  eye. 

Operation. — Xov.  29,  1899.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion.  Ptosis  of  rt.  lasted  18  days.  Hyperemia 
of  conjunctiva  and  lachrymation  lasted  three  days.  No  acci- 
dents or  complications.  R..V.  improved  to  20/50  and  pupil 
contracted.  T.  n.,  later  became  slightly  plus.  Pain  disap- 
peared within  24  hours. 

9.  St.  Louis  Med.  Review,  Feb.  1,  1902. 


78 

Last  report  April,  1903.  R.  V.=20/50.  L.  V.— 20/20.  Xo 
ptosis.  Good  condition  continues. 

CHRONIC   SIMPLE  GLAUCOMA,  BOTH.    BILATERAL  SYMPATHECTOMY. 
SLIGHT    IMPROVEMENT. 

Nos.  37  AND  38. — M.,  aged  52.  Double  simple  glaucoma. 
Duration  18  months.  R.  V.  quantitative.  L.  V.=Lai'ge  ob- 
jects at  6  ft.  In  both  eyes  T.+2.  Pupils  dilated,  discs  mark- 
edly cupped.  Fields  not  taken. 

Operation. — March  11,  1901.  Bilateral  excision  of  sup. 
cerv.  ganglia.  Ptosis  lasting  two  weeks.  Hyperernia  of  con- 
junctiva and  some  lachrymation  for  several  days.  Pupils 
contracted.  T.+l.  Vision  improved  to  6/100  in  each. 

Last  report  two  years  after  operation  shows  that  improve- 
ment has  been  retained,  although  tension  is  still  plus. 

CHRONIC   SIMPLE  GLAUCOMA,   LEFT.    BILATERAL   SYMPATHECTOMY. 
SLIGHT    IMPROVEMENT. 

Nos.  39  AND  40. — F.,  aged  40.  Simple  glaucoma  of  left 
eye  of  7  months'  duration.  R.  V.=20/20.  T.  n.  Normal  in 
every  way.  L.  V.=F.  3  ft.  T.+3.  Pupil  dilated  and  fixed. 
Disc  markedly  cupped.  Fields  not  taken. 

Operation. — Sept.  9,  1901.  Bilateral  excision  of  sup.  cerv. 
sympath.  ganglia.  Bilateral  ptosis  for  16  days.  Hypereinia 
of  conjunctiva  and  increased  lachrymation  for  3  days.  Hys- 
terical manifestations.  T.  n.,  pupils  contracted  and  L.  V.=F. 
14  ft.  No  fields. 

Last  report  April,  1903.     Same  condition. 

CHRONIC  IRRITATIVE  GLAUCOMA,  RIGHT.      BILATERAL  SYMPATHEU- 
TOMY.       IMPROVEMENT. 

Nos.  41  AND  42. — M.,  aged  39.  Duration  of  disease  in  viulit 
eye  15  months.  Attacks  of  pain  at  times.  R.  V.=P.l.  T.-j-2. 
Pupil  dilated,  media  hazy,  disc  sharply  cupped.  L.  V  .=20/20. 
T.  n.  Media  and  fundus  normal.  Eye  normal  in  every  way. 
No  fields  were  taken. 

Operation. — Feb.  12,  1902.  Bilateral  excision  of  sup.  cerv. 
sympath.  ganglia.  Bilateral  ptosis  for  2  weeks.  Some  injec- 
tion of  conjunctiva  and  increased  lachrymation  for  several 
days.  P,ain  relieved.  R.  V.=F.  12  ft.  T.  n.,  pupil  contracted. 

April,   1903.     Last  report.     Same  improved  condition. 

ACUTE    GLAUCOMA,     RIGHT.       BILATERAL     SYMPATHECTOMY.       IM- 
PROVEMENT. 

Nos.  43  AND  44. — M.,  aged  57.,  History  of  acute  glaucoma 
in  right  eye  for  3  weeks.  Severe 'pain.  R.  V.=20/100.  T.+3. 
Pupil  dilated  and  fixed.  Very  slight  cupping  of  disc.  L.  V. 
—20/20.  Eye  in  every  way  normal.  No  fields  taken. 

Operation. — June  22,  1902.     Bilateral  excision  of  sup.   cerv. 


79 

sympath.  ganglia.  Pain  in  eye  disappeared.  Ptosis,  bilateral, 
for  13  days.  Conjuuctival  hyperemia  and  lachryraation.  Pupil 
contracted.  R.  V.=20/40. 

In  April,  1903,  at  time  of  last  report,  no  return  of  the 
trouble. 

CHRONIC   IRRITATIVE  GLAUCOMA,   RIGHT.      BILATERAL   SYMPATHEC- 
TOMY.        SLIGHT    IMPROVEMENT. 

Xos.  45  AND  46. — M.,  aged  46.  Duration  11  months.  His- 
tory of  attacks  of  pain  in  right  eye.  R.  V .=20,  200.  T.+2. 
Pupil  dilated.  Disc  cupped.  L.  V.=20/20.  Eye  normal  in 
every  way.  No  fields  taken. 

Operation. — Nov.  16,  1902.  Bilateral  excision  of  sup.  cerv. 
sympath.  ganglia.  Ptosis  for  12  days,  pronounced  hyper- 
en:ia  of  conjunctiva  and  moderate  increase  of  lachrymation. 
Pupils  contracted  and  tension  in  rt.  eye  reduced.  R.  V.= 
20/100.  L.  Y.=20/20. 

Favorable  result  continues  at  time  of  last  report,  April, 
1003. 

No  recurrence  in  any  of  these  cases  up  to  date  of  report, 
April,  1903.  In  the  irritative  cases  the  pain  was  relieved  in 
every  instance.  Xo  difference  was  noted  in  the  anterior  cham- 
ber in  any  case.  In  the  last  four  cases  the  ganglion  was  torn 
from  its  attachment  with  a  strong  forceps  instead  of  being  cut. 

G.    E.    DE  SCHWEINITZ.       ONE    CASE.       CHRONIC    CONGESTIVE    GLAU- 
COMA, BOTH.      BILATERAL  SYMPATHECTOMY.      UN- 
CERTAIN   RESULTS. 

Xos.  47  AND  48. — M.,  aged  23.  Duration  7  months.  R.  V. 
=shadows  on  temporal  side.  T.+2.  Pupil  dilated  5  to  6  mm. 
Light  field  on  temporal  side  only.  L.  V.=shadows  imperfectly. 
T.+2.  Pupil  dilated  8  mm.  Fields  contracted  so  that  there 
was  only  light  perception  on  temporal  side.  Green,  atrophic, 
completely  cupped  discs  on  each  side  with  typical  halo. 

Operation. — Dec.  14,  1901.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion  and  a  considerable  piece  of  the  nerve. 
Slight  ptosis  followed  and  congestion  of  conjunctiva.  T. 
slightly  diminished.  Pupil  contracted  3  mm.,  but  this  lasted 
only  3  days.  R.  V.=uncertain  counting  of  fingers  in  temporal 
field. 

Operation. — Jan.  31,  1902.  Excision  of  left  ganglion.  Xo 
improvement  in  vision.  Xo  change  in  tension,  pupil  or  field. 
After  first  operation  decided  dysphagia  lasting  48  hours.  Pa- 
tient remained  free  from  congestive  attacks  of  glaucoma  for 
two  months,  then  they  returned. 

JOHN    R.    SHANNON.       ONE    CASE.       CHRONIC    SIMPLE    GLAUCOMA, 
BOTH.      LEFT    SYMPATHECTOMT.       NO    IMPROVEMENT. 

No.  49. — F.,  aged  32.  Disease  existed  for  10  years  in 
both  eyes.  R.  V .=15/200.  T. —  (?).  Pupil  large,  irregular. 


80 

a.  c.  deep.  No  peripheral  vision  except  in  lower  temporal 
quadrant.  L.  V.=hand  movements  centrally,  F.  3  ft.  ex- 
centrically.  T.+l.  Coloboma  from  iridectomy  upwards. 
Both  discs  slightly  cupped. 

Operation. — June  18,  1902.  Excision  of  left  sup.  cerv. 
sympath.  ganglion.  No  change  in  pupil  and  tension  remained 
increased  as  before.  Slight  ptosis. 

Fields  remained  the  same  April  14,  1903. 

J.   H.    SHORTER.      ONE   CASE.      SECONDARY   GLAUCOMA   AFTER    SYM- 
PATHETIC  INFLAMMATION.      LEFT   SYMPATHECTOMY. 
SLIGHT    IMPROVEMENT.10 

No.  50. — M.,  aged  20.  Lost  right  eye  from  trauma.  Glau- 
coma in  left  eye  for  six  years  following  sympathetic  oph- 
thalmia. L.  V.=F.  3  ft.  T.+2.  Pupil  fixed  from  posterior 
synechise.  Disc  not  visible  on  account  of  central  cataract. 
Large  defect  on  nasal  side  of  field. 

Operation. — 1901.  Excision  of  left  sup.  cerv.  sympath. 
ganglion.  After  operation  profuse  lachrymation  and  mucous 
discharge  from  left  nostril.  Conjunctiva  and  skin  of  face  were 
injected.  Left  ptosis.  L.  V.=F.  6  ft.  T.  n.  one  month  after 
operation. 

Final  examination  showed  less  contraction  of  visual  fields. 
Anesthesia  of  left  auricle.  Transitory  hoarseness. 

ELMER    G.     STARR.      ONE    CASE.      SIMPLE    GLAUCOMA,    BOTH.      POS- 
TERIOR  SCLEROTOMY.      BILATERAL   SYMPATHECTOMY. 
MARKED     IMPROVEMENT. 

Nos.  51  AND  52. — F.,  aged  63.  Duration  one  year.  Dis- 
ease had  been  held  in  check  for  nine  months  with  eserin,  until 
by  mistake  patient  used  atropin,  which  caused  reduction  of 
vision  to  F.  4  ft.  and  increase  of  tension  to  +3.  Sclerotomy 
of  right  eye  increased  vision  to  F.  18  ft.  Marked  cupping  of 
both  discs  with  some  atrophy.  Immediately  before  sympathec- 
tomy  R.  V.=F.  18  ft.  T.+2.  Pupil  moderately  dilated. 
L.  V.=F.  4  ft.  T.  n.  Pupil  moderately  dilated.  Fields  of 
both  eyes  typically  contracted. 

Operation. — Oct.  163  1902.  Bilateral  excision  of  sup.  cerv. 
sympath.  ganglia.  Result  on  lid,  conjunctiva,  etc.,  nil.  R.  V. 
=20/50.  T.+  l.  Pupil  normal.  L.  V.=20/50.  T.  n.  Pupil 
normal. 

Last  report  April  15,  1903,  states  that  above  condition  per- 
sists, but  that  visual  fields  have  decreased  somewhat.  For 
two  or  three  weeks  after  operation  inability  to  raise  the  arms. 
This  disappeared.  Painful  sensation  at  times  in  the  neck. 

10.  Medical  News,  April  6,  1901. 


81 

GEO.      F.      SURER.        FOUR      CASES.        FIVE      OPERATIONS.        SIMPLE 

CHRONIC   GLAUCOMA.   BOTH.      ABSOLUTE   GLAUCOMA,   RIGHT. 

RIGHT    SYMPATHECTOMY.      NO    IMPROVEMENT.11 

No.  53. — M.,  aged  70.  Duration  about  two  years.  R.  V. 
=0.  T.+3.  Pupil  dilated,  a.  c.  shallow.  Fields  could  not  be 
taken.  L.  V.=20/200.  T.  n.  Nasal  field  contracted.  Optic 
discs  in  both  cupped.  Iridectomy  on  left  eye  in  1898. 

Operation. — August,  1899.  Excision  rt.  sup.  cerv.  sympath. 
ganglion.  Hyperemia  of  conjunctiva,  flushing  of  side  of  face 
and  increased  lachrymation.  No  other  accidents.  Pupil  con- 
tracted and  remained  so  for  three  years.  No  change  in  fields, 
tension  or  vision. 

Last  observation  June,  1902. 

SIMPLE  CHRONIC  GLAUCOMA,  BOTH.    BILATERAL  SYMPATHECTOMY. 
NO    IMPROVEMENT. 

No.  54  AND  55. — M.,  aged  65.  Duration  between  one  and 
two  years.  R.  V.=F.  8  ft.  T.+2.  Pupil  dilated  and  a.  c. 
rather  deep.  Pupil  concentrically  contracted.  Glaucoma  cup- 
ping of  disc.  L.  V.=F.  10  ft.  T.+.  Pupil  and  fields  as  above. 
Disc  not  distinctly  seen  on  account  of  cataractous  lens. 

Operation. — November,  1899.  Bilateral  excision  of  sup.  cerv. 
sympath.  ganglion.  Hyperemia  of  conjunctiva  followed. 
Pupils  contracted  and  central  vision  improved  slightly.  Fields 
enlarged  somewhat  and  then  contracted  to  less  than  before  the 
operation. 

Last  observation  April,  1903.     Sees  enough  to  get  about. 

CHRONIC    INFLAM.    GLAUCOMA,    LEFT.       LEFT    SYMPATHECTOMY. 
SLIGHT    IMPROVEMENT. 

No.  56. — F.,  aged  67.  Disease  of  two  or  three  years'  dura- 
tion in  left  eye.  R.  V.=20/40.  T.  n.  Pupil  normal.  Fields 
normal.  L.  V.=20/100.  T.+2.  Pupil  dilated.  Disc  shows 
considerable  cupping.  Fields  contracted  on  nasal  side. 

Operation. — September,  1899.  Excision  of  left  sup.  cerv. 
sympath.  ganglion.  Slight  ptosis.  Increased  lachrymation. 
T.  n.  Pupil  contracted.  Fields  enlarged  considerably.  L.  V. 
—20/100. 

Last  observation  April,  1902.  Fields  slightly  enlarged  as 
compared  with  those  before  operation.  L.  V.=20/100.  Patient 
died  in  1902. 

ABSOLUTE  GLAUCOMA,  RIGHT.    CHRONIC  INFLAM.  GLAUCOMA,  LEFT. 

PREVIOUS  IRIDECTOMY  ON  LEFT.      RIGHT  SYMPATHEp- 

TOMY.      NO    IMPROVEMENT. 

No.  57. — M.,  aged  58.  History  of  painful  attacks  of  glau- 
coma for  over  one  year  in  both  eyes.  R.  V.=0.  T.+3.  Pupil 

11.  THE  JOURNAL  A.  M.  A.,  1901. 
6 


82 

dilated,  a.  c.  shallow.  Xo  fields.  L.  V.=20/80.  T.  n.  Fields 
normal.  Iridectomy  had  been  done  sometime  before. 

Operation. — January,  1900.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion.  No  effect  on  lid,  tension,  etc.  Pupil  con- 
tracted. T.+l.  Xo  change  in  central  vision  or  fields. 

In  two  of  these  four  cases  there  was  dysphagia  lasting  sev- 
eral days. 

DAVID    WEBSTER.      ONE    CASE.      RIGHT,    SIMPLE   GLAUCOMA.      LEFT, 
ABSOLUTE    GLAUCOMA.      RIGHT   SYMPATHECTOMY,    TEMPOR- 
ARY   IMPROVEMENT.       DISEASE    STATIONARY. 

No.  58. — M.,  aged  49.  Disease  for  one  year  in  left  eye 
and  a  few  months  in  the  right.  R.  V.=20/50.  T.+.  Pupil 
slightly  dilated  and  sluggish.  Field  up  40°,  down  50°,  nasal 
50°,  temporal  85°.  White  disc  with  shallow  excavation.  L.  V. 
=0.  T.+3.  Pupil  widely  dilated,  deep  glaucoma  cupping. 

Operation. — Feb.  5,  1902.  Excision  of  rt.  sup.  cerv.  sympath. 
ganglion.  Ptosis  followed.  Numbness  of  right  side  of  tonkin- 
and  hoarseness.  T. — .  Contracted  pupil.  R.  V.=2o  •"><>. 
Fields  improved. 

Last  report  Jan.  22,  1903,  one  year  later.  R.  V.=2d  .*>u. 
Fields  about  the  same  as  before  the  operation.  T.  n.  Miosis, 
slight  ptosis. 

JOHN     E.     WEEKS.       FIVE     CASES.        SEVEN     OPERATIONS.        SI.Ml'I.K 
CHRONIC    GLAUCOMA,    RIGHT.     RIGHT    SYMPATHECTOMY,    TEM- 
PORARY   IMPROVEMENT.       ACUTE    ATTACK.       IRIDECTOMY." 

No.  59. — F.,  aged  56.  Duration  of  disease  two  years.  R.  V. 
=F.  1  ft.  T.+2.  Pupil  dilated,  a.  c.  shallow.  Cupping  of 
optic  disc.  Field  for  white  small,  color  field  abolished.  L.  V. 
=20/20.  T.+l-  Fields  not  much  contracted. 

Operation. — March  11,  1902.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion.  Vision  began  to  steadily  improve  and  she 
could  see  colors.  Fields  increased  markedly.  Tension  re- 
mained plus.  April  20,  1902,  R.  V.=r 20/70.  T.+l.  June  8, 
1902,  attack  of  acute  glaucoma  in  right.  V.=P.l.  June  20, 
1902.  Iridectomy  of  right  eye.  July  18,  1902,  R.  V.=F.  7  ft. 
L.  V.— 20/20. 

SIMPLE    GLAUCOMA     (ABSOLUTE).    RIGHT.     SUBACUTE    GLAUCOMA. 

L«FT.      LEFT  SYMPATHECTOMY,   IMPROVEMENT.      RIGHT. 

SYMPATHECTOMY. 

Nos.  60  AND  61. — M.,  aged  70.  History  of  6  months'  dura- 
tion. R.  V.=P.l.  T.+2.  Nerve  white  and  deeply  cupped. 
L.  V.=20/40.  T.+2.  Fields  contracted. 

Operation. — April  1,  1902.  Excision  of  left  sup.  cerv. 
sympath.  ganglion.  T. — .  No  untoward  symptom. 

Operation  April   15.   1902,  on  right  side.     No  untoward  re- 

12.   Trans.  Amer.   Ophth.    Soc..   1902. 


83 

suits.     July  5,    1902,  R.  V.=P.l.     No  change  in   fields.     L.  V, 
=20/20.     Fields  markedly   improved. 

SIMPLE  CHRONIC  GLAUCOMA,  LEFT.     ABSOLUTE  GLAUCOMA,  RIGHT, 
LEFT    SYMPATHECTOMY,    IMPROVEMENT. 

No.  62.— R.V.=0.  T.+3.  L.  V.=20/70.  T.+.  Duration 
of  disease  seven  years,  during  which  time  he  had  used  eserin. 
Fields  greatly  contracted. 

Operation. — April  15,  1902.  Excision  of  left  sup.  cerv. 
sympath.  ganglion.  T.  n.  Pupil  small.  Suffusion  of  eye, 
lachrymation  increased.  Ten  days  later  L.  V.=20/30+. 

July  10,  1902,  severe  pain  in  left  side  of  head.  L.  E.  T.+. 
L.  V.=20/20.  Fields  increased.  No  later  report. 

SIMPLE    GLAUCOMA,    BOTH.       BILATERAL    SYMPATHECTOMY,    TEM- 
PORARY    IMPROVEMENT.        LATER     IRIDECTOMY    NECESSARY. 

Nos.  63  AND  64. — M.,  aged  30.  History  of  failing  vision 
and  increased  tension  in  both  eyes  for  three  years.  R.  V.= 
20/40+.  T.+1.5.  Pupil  dilated,  optic  disc  cupped,  fields  con- 
tracted. 

Operation. — April  29,  1902.  Excision  of  rt.  sup.  cerv, 
sympath.  ganglion.  Pupil  contracted.  T.  n.  Acute  attack 
of  glaucoma  was  excited  in  left  eye.  L.  V.=l/200. 

Operation. — May  6,  1902.  Excision  of  left  ganglion.  Pupil 
contracted.  T.+l-  Improvement  in  vision.  T.  of  right  eye- 
remained  normal.  T.  of  left  remained  high  and  iridectomy  was 
done.  July  12,  1902,  R.  V.=20/20.  L.  V.=9/200. 

Last  report  March  1,  1903.  Iridectomy  was  done  on  right 
eye  because  of  periodic  increase  of  tension  and  diminution  of 
vision  and  visual  fields.  April  11,  1903,  R.  V— 20/40.  T.  n. 
L.V.=F.  17  ft. 

SIMPLE  CHRONIC  GLAUCOMA,  BOTH.      LEFT  IRIDECTOMY,  FOLLOWED' 
LATER    BY    LEFT    SYMPATHECTOMY,    IMPROVEMENT. 

No.  65. — M.,  aged  40.  Duration  of  disease  unknown. 
R.  V.=0.  Absolute  glaucoma.  T.+3.  Deep  cupping  of  disc. 
L.  V.=F.  5  ft.  T.+.  Pupil  shows  coloboma  after  iridectomy. 
Cupping  of  optic  disc. 

Operation. — Dec.  2,  1902.  Excision  of  left  sup.  cerv.  sympath. 
ganglion.  Ptosis,  suffusion  of  conjunctiva,  increased  lachryma- 
tion and  nasal  mucus  and  free  perspiration  on  side  of  face 
opposite  to  side  of  operation  occurred.  Improvement  in  ten- 
sion and  vision  occurred,  and  at  time  of  last  report,  three 
months  after  operation,  T.  n.,  L.  V.=20/200. 

The  ganglion  was  small,  not  much  larger  than  trunk  of 
the  nerve.  It  was  very  pale  in  color. 

MEYER     WIENER.        TWO     CASES.        CHRONIC     INFLAM.     GLAUCOMA, 
RIGHT.      RIGHT    SYMPATHECTOMY.       NO   IMPROVEMENT. 

No.   66.— F.,   aged   50.     R.  V.=F.      12    ft.      T.+2.      Dilated 


84 

pupil.     Cupped  disc.     L.  V.=0.   Phthisis  bulbi.     Field  of  right 
contracted. 

Operation. — Winter  of  1900.  Excision  of  rt.  sup.  cerv. 
sympath.  ganglion.  No  change  in  vision  or  tension  and  pa- 
tient was  lost  sight  of  in  four  weeks  after  operation. 

CHRONIC     SIMPLE    GLAUCOMA,     RIGHT.       RIGHT    SYMPATHECTOMY. 
NO  IMPROVEMENT  EXCEPT  IN  PUPIL. 

No.  67. — F.,  aged  45.  Duration  of  disease  in  right  eye  4 
years.  T.+  l.  Pupil  dilated.  Field  slightly  contracted  on 
inner  side.  R.  V.=6/200.  L.  V.=6/6.  T.  n.  Eye  normal. 

Operation. — 1900.  Excision  of  rt.  sup.  cerv.  sympath.  gang- 
lion. No  change  in  tension  or  pupil.  Vision  remained  the 
same.  Patient  disappeared  three  weeks  after  the  operation 
and  no  further  report  was  made. 

H.    W.    WOODRUFF.     ONE    CASE.       SIMPLE    GLAUCOMA,    LEFT.       LEFT 

SYMPATHECTOMY    WITH   TEMPORARY   IMPROVEMENT. 

LATER  IRIDECTOMY.13 

No.  68. — M.,  aged  29.  Failure  of  right  eye  for  7  years  after 
an  injury.  Duration  in  the  left  eye  three  years.  R.  V.=0. 
Absolute  glaucoma.  T.+.  Deep  cupping  of  disc.  L.  V.= 
20/40.  T.+.  Pupil  dilated.  Fields  contracted,  cupping  of 
optic  disc. 

Operation. — April  29,  1901.  Excision  of  left  sup.  cerv. 
sympath.  ganglion.  Six  days  later  ptosis.  T.  n.,  contracted 
pupil,  improved  vision.  White  fields  that  were  contracted  to 
10°  increased  to  30°  up,  30°  nasal,  15°  below  and  50°  tem- 
poral with  irregular  outline.  Later  central  vision=20/20. 
Six  months  later  he  had  return  of  all  symptoms  and  failing 
central  vision.  He  refused  iridectomy,  but  later  consented  to 
it,  and  on  Feb.  10,  1902,  iridectomy  of  the  left  eye  was  done. 
Central  vision  improved  to  20/30. 

Last  report  March  10,  1903,  L.  V.=20/70.  T.  n.  Field 
greatly  contracted.  Above  5°,  temporal  2°,  below  5°,  nasal  10°. 

We  have  here  records  of  68  operations  done  on  54 
cases,  i.  e.,  14  were  bilateral.  Of  these  operations.  38 
were  for  simple  glaucoma;  16  for  chronic  inflammatory 
glaucoma;  4  for  subacute  glaucoma;  3  for  acute  glau- 
coma; 4  for  absolute  glaucoma;  2  for  hemorrhagic 
glaucoma;  1  for  buphthalmus. 

Of  these  five  operations  were  preventive,  one  by  Hale 
(20),  four  by  Eenaud  (40,  42,  44,  46) .  No  glaucoma  up 
to  time  of  reports.  One  death  occurred  (30).  Of  the  38 
operations  for  simple  glaucoma,  14  gave  no  improve- 
ment whatsoever.  Five  were  temporarily  improved 

13.  Chicago  Med.  Recorder,  July,  1901. 


85 

for  periods  ranging  from  fifteen  days  to  eight  months, 
but  had  recurrent  attacks  that  necessitated  iridectomy 
or  caused  loss  of  the  eye.  Fifteen  were  improved  as 
long  as  they  were  under  observation,  for  periods  of  from 
two  months  to  two  years.  Of  these  three  were  sta- 
tionary (5,  17,  58)  ;  one  died  (30)  ;  six  remained  un- 
improved after  iridectomy,  but  improved  after  sympa- 
thectomy  (17,  18,  24,  34,  35,  65). 

Concerning  the  15  that  were  improved,  No.  9  showed 
slight  improvement;  No.  18  improvement  as  to  tension; 
previous  iridectomy  had  been  done;  observation,  one 
year;  No.  24,  improvement  as  to  central  vision  and 
tension;  No.  29,  marked  improvement;  observation, 
fourteen  months;  No.  34,  previous  iridectomy  had  been 
done;  improvement  after  sympathectomy,  but  patient 
was  only  under  observation  for  fifteen  days;  No.  35, 
previous  iridectomy,  after  the  sympathectomy  the  ten- 
sion remained  minus;  Nos.  37  and  38,  slight  improve- 
ment as  to  vision,  but  tension  is  still  plus;  time  of  ob- 
servation, two  years ;  No.  40,  improvement  as  to  tension, 
slight  improvement  as  to  vision;  time  of  observation, 
twenty  months;  Nos.  51  and  52,  marked  improvement 
in  tension  and  vision;  posterior  sclerotomy  had  been 
done  without  effect ;  time  of  observation,  six  months ; 
Nos.  62  and  65,  previous  iridectomy;  marked  improve- 
ment intension  and  vision;  time  of  observation,  four 
months ;  Nos.  4  and  6  showed  marked  improvement,  and 
have  been  under  observation  for  nine  months  and  four 
months,  respectively. 

Of  the  16  operations  for  chronic  inflammatory,  6 
showed  no  improvement;  3  showed  improvement  for 
periods  from  two  to  three  months  (2,  31,  50)  ;  4  were 
improved  as  long  as  they  were  under  observation;  1  (45) 
five  months,  1  (15)  eighteen  months,  1  (41)  one  year, 
1  (36)  three  years. 

Of  these  1  (15)  had  not  been  benefited  by  iridce- 
tomy,  but  greatly  improved  by  sympathectomy;  eight- 
een months  under  observation;  3  (20,  42,  46)  were 
preventive,  and  disease  had  not  appeared  at  three 
months,  eight  months  and  one  year  after  operation. 

Of  the  four  that  showed  improvement,  No.  15  is 
the  most  interesting,  because  an  iridectomy  failed  to 
check  the  disease,  but  sympathectomy  produced  marked 
results  in  central  and  peripheral  vision.  Time  of  ob- 
servation, eighteen  months. 


86 

In  Xo.  36,  improvement  in  central  vision  continued 
after  three  years,  tension  slightly  plus;  in  No.  41,  im- 
provement continues  after  one  year;  in  No.  45,  vision 
and  tension  were  improved  and  pain  was  relieved ;  time 
of  observation,  five  months. 

No.  20  is  interesting  in  that  the  operation  was  done 
for  threatened  glaucoma. 

In  Xos.  42  and  46  it  is  not  stated  whether  the  bi- 
lateral operation  was  done  to  influence  more  profoundly 
the  diseased  eye  or  to  prevent  the  occurrence  of  the 
disease  in  the  perfectly  sound  eye.  The  same  may  be 
said  concerning  Cases  39  and  44,  in  which  one  eye 
was  normal  in  every  respect. 

Of  the  4  operations  for  subacute  glaucoma,  1  (12) 
cured  at  the  end  of  two  and  a  half  years  (Black)  ;  2 
(27,  28)  remained  well  at  end  of  fifteen  months  (La- 
Motte)  ;  1  (60)  remained  improved  after  observation 
of  four  months  (Weeks). 

Of  the  three  operations  for  acute  glaucoma,  1  (26) 
recovered:  observation,  fifteen  months  (LaMotte)  ;  1 
(43)  improved;  remained  so  after  nine  months  (Re- 
naud)  ;  1  (44)  preventive;  no  attack  occurred. 

Of  the  four  operations  for  absolute  glaucoma,  1  (8) 
improved  as  to  pain;  3,  no  improvement  and  no  change. 

Of  the  two  operations  for  hemorrhagic  glaucoma,  1 
(11)  improved  as  to  pain;  1  (33),  improved  vision 
during  time  of  observation,  five  months. 

One  operation  for  buphthalmus  had  no  effect. 

SUMMARY. 

Xo.  of  Temporarily     Sta-  Unim 

Form  of  Glaucoma.     Cases.   Improved.   Improved,  tlonary.  proved. 

Simple  chronic 38  15  5  3  15 

Chronic  inflammatory   ..16                4  3  3  6 

Subacute 4                3  1 

Acute 3                1  1  1 

Absolute    4                1  ..  ..  3 

Hemorrhagic     2  2 

Buphthalmus    1  ; ."  •  . .  . .  1 

68  26  10  7  25 

After  these  68  operations  miosis  is  mentioned  as  oc- 
curring 40  times,  and  this  condition  remained  for 
periods  ranging  from  two  days  to  three  years.  In  most 
cases  it  seems  to  be  permanent.  It  is  mentioned  that 
in  34  cases  the  tension  was  reduced  to  normal,  and  in 
9  others  it  was  much  lower  than  it  was  before  the  opera- 
tion. As  to  the  effect  of  the  operation  on  the  lid,  con- 
junctiva, face,  etc.,  ptosis  occurred  in  36  cases  and  lasted 


87 

for  periods  ranging  from  thirteen  days  to  one  year. 
This,  like  miosis,  is  one  of  the  most  constant  phenom- 
ena. Conjuiictival  congestion  was  noted  in  19  cases, 
lasting  fox  a  variable  time,  usually  not  longer  than  a 
few  days.  One  case  persisted  for  three  months.  In- 
creased lachrymation  was  observed  in  18  of  the  cases. 
This  was  of  short  duration,  but  in  one  case  lasted  three 
weeks.  Congestion  of  the  face  on  the  side  operated  on 
was  observed  six  times,  in  one  case  lasting  three  months. 

Xeuralgia  and  hyperesthesia  of  the  side  of  the  face 
operated  on  was  noted  in  six  cases>  lasting  in  one  case 
for  one  year.  Anesthesia  of  the  face  or  neck  on  the 
operated  side  was  mentioned  in  only  two  cases;  in  one 
of  them  it  lasted  three  months.  Hoarseness  or  aphonia 
occurred  in  8  cases,  lasting  for  a  variable  time,  from  one 
week  to  three  weeks.  In  two  of  the  cases  dysphonia  was 
the  result  of  paralysis  of  the  recurrent  laryngeal,  and 
lasted  in  one  for  nine  months  and  in  the  other  for  two 
years.  Dysphagia  was  observed  in  5  cases  as  a  result 
of  the  operation.  This  symptom  lasted  only  two  or 
three  days,  except  in  one  case,  in  which  it  persisted  for 
six  months.  In  one  case  (5),  for  a  period  of  several 
days  after  the  operation,  the  patient  had  mild  hal- 
lucinations. 

The  results  exhibited  in  this  series  of  cases,  at  first 
glance,  do  not  seem  as  favorable  as  those  presented  by 
Rohmer,14  who  drew  conclusions  from  a  study  of  74 
cases  collected  by  Bichat,  to  which  he  added  20  of  his 
own.  On  these  94  cases,  114  operations  were  done.  The 
following  table  gives  a  summary  of  the  results  of  their 
analysis  of  these  cases : 

No.  of  Cases 
Form  of  Glaucoma.     Operated  on.     Improved.     Negative.     Worse. 

Simple   chronic    43  36                     5                   2 

Chronic  inflammatory 34  23  10                   1 

Subacute    14  6                    6                  2 

Acute 9  4                     5 

Absolute    3  1                    2 

Hemorrhagic     5  5 

Hydrophthalmus     6  4                     1                   1 

114  79  29  6 

The  statistics  of  Ziehe  and  Axenfeld,15  who  studied 
the  results  in  55  cases,  agree  with  this  in  the  main,  for 
many  of  the  cases  in  each  series  are  the  same.  Un- 

14.  Annales  d'Oculistique,   May,  1902. 

15.  Ziehe   and   Axenfeld :    Sympathicus   Resection    beim   Glaukom. 
Rostock.    1901. 


88 

fortunately,  many  of  these  cases,  as  in  the  present  series, 
either  do  not  give  the  final  result,  or  were  under  ob- 
servation such  a  short  time  as  to  make  any  statement 
as  to  the  final  outcome  impossible.  Again,  in  studying 
them,  it  is  seen  that  the  records  of  many  of  them  are 
far  from  exact. 

However,  to  quote  Axenfeld:  "There  is  obtained  by 
this  operation  in  a  certain  proportion  of  cases  of  simple 
glaucoma,  a  definite  and  important  result,  and,  in  some 
instances,  there  has  been  a  decided  improvement,  even 
where  a  previous  iridectomy  had  failed."  Such  cases 
as  those  reported  by  Grunert,16  Demicheri,17  Cutler, 
Starr18  and  Weeks,18  in  which  sclerotonw  and  iridec- 
tomy had  been  unsuccessfully  performed,  and  sympathec- 
tomy  accomplished  not  only  reduction  in  tension  but 
improvement  in  both  central  and  peripheral  vision, 
speak  strongly  in  favor  of  the  operation  in  certain 
cases. 

As  was  said  in  the  beginning,  I  feel  that  positive  con- 
clusions are  not  yet  to  be  reached,  and  will  not  be  until 
more  carefully  selected  cases  can  be  studied  for  longer 
periods  of  time. 

The  operation  in  itself,  while  a  major  one,  is  not  to 
be  considered  one  of  unusual  danger,  and  with  modern 
technic  should  show  a  very  trifling  mortality.  The  death 
recorded  in  our  present  series  was  purely  accidental, 
and  might  have  occurred  in  any  other  operation  on  the 
neck.  With  such  brilliant  results  before  us  as  are 
presented  in  certain  cases  on  record,  we  must  agree 
that  sympathectom)'  is  not  an  operation  to  be  con- 
demned too  hastily.  It  certainly  is  not  fair  to  condemn 
it  when  it  fails  to  restore  sight  to  an  eye  that  has  suf- 
fered so  long  from  glaucoma  that  it  is  blind  from 
atrophy  of  the  nerve,  or  when  it  fails  to  check  pain  in 
an  eye  that  is  hopelessly  lost  from  absolute  glaucoma. 

If  it  is  to  be  compared  with  iridectomy  at  all,  it 
should  be  given  an  early  trial  in  any  form  of  the  disease 
in  which  it  is  applicable. 

The  statistics  up  to  date  seem  to  indicate  that  the 
simple  chronic  form  is  the  one  most  suited  for  it,  next 
to  the  hemorrhagic  form,  if  that  can  be  determined.  As 

16.  Archiv.  f.  Augenheilk.,  1900,  vol.  xlii. 

17.  Annales  d'Oculistique,  T  cxxi,  1899. 
18  Loc.  cit. 

19.  Loc.  cit. 


89 

a  guide  for  my  own  practice,  I  should  feel  very  much 
like  following  Abadie-0  when  he  says :  "In  acute  forms 
of  glaucoma  and  in  subacute  with  intermissions,  prac- 
tice first  iridectomy,  and  if  it  fails  do  sympathectomy. 
In  simple  glaucoma  use  miotics  twice  a  day ;  if  they 
suffice,  continue  them.  If,  in  spite  of  their  systematic 
employment  the  vision  fails,  do  sympathectomy." 

BIBLIOGRAPHY. 

Doyon  :   Bulletin  de  Lyons,  June,  1897. 

Jonnesco :  Sympathectomy  for  Exoph.  Goiter  and  Epilepsy. 
Internat.  Med.  Congress.  Moscow,  1897  ;  Wiener  Klin.  Woch.,  May 
4.  1899  ;  Resection  of  Cervical  Sympathetic  Ganglion,  International 
Clinics,  1902,  11. 

Jonnesco  and  Floresco :  Sur  les  phe'nomenes  consecutif  a  la 
resection  du  sympathetique  cervical  chez  1'homme,  Bulletin  Acad.  de 
Med.,  Paris,  July  1-8,  1902.  :  '" 

Abadie :  Annales  d'Oculistique.  T.  119,  p.  Il4,  l'898 ;  Archives 
d'Ophthalmologie,  July,  1898 :  La  Clinique  Ophth.,  Feb,  25.  1901 ; 
Internat.  Med.  Congress,  Paris,  1900  ;  Zeitschrift  f.  Augenheilkunde, 
iv,  s.  255  ;  Archives  d'Ophthalmologie,  May,  1901. 

Panas  :  Archives  d'Ophthalmologie'  July  6,  1898. 

Ball,  J.  M.  :  New  York  Med.  Jour.,  1899,  vol.  Ixx ;  THE  JOUEXAL 
Amer.  Med.  Assn.,  June  2,  1900. 

Coover,  D.  H.  :  Removal  of  Cerv.  Sympath.  Ganglion  for  Relief 
of  Glaucoma,  Phila.  Med.  Jour.,  March  16,  1901  ;  also,  Ophthalmic 
Record,  March,  1001. 

Dodd,  H.  Work  :  Resection  of  Superior  Cerv.  Sympath.  Ganglion 
for  Glaucoma,  Lancet,  1900,  vol.  xi,  p.  1071,  and  Lancet,  March  23, 
1901. 

Galowin  :  Optico-ciliary  Neurectomy  in  Absolute  Glaucoma,  Zeit- 
schrift f.  Augenheilkunde,  Berlin,  July,  1901. 

Whitehead,  A.  L.  :  Treatment  of  Glaucoma  by  Excision  of  Sup. 
Cerv.  Ganglion  of  Sympathetic,  Lancet,  London,  July  6,  1901. 

Ziehe  and  Axenfeld  :  Sympathicus  Resection  beim  Glaukom,  1901 ; 
Aus  der  Augenklinik  in  Rostock. 

Axenfeld  :  Klin.  Monatsbl.  f.  Augenheilkunde,  Bd.  xxxviii.  August, 
September. 

Dunn,  John  :  Glaucoma,  Va.  Med.  Semi-Monthly,  Oct.  11,  1901. 

Black :  Melville :  Resection  of  Superior  and  Middle  Cervical 
Ganglion  of  the  Sympathetic  for  Glaucoma,  Ophthalmic  Record, 
October,  1901. 

Kipp,  N.  J.  :  Discussion  of  Glaucoma,  Trans.  Amer.  Ophthal. 
Soc.,  1901,  p.  309. 

Levinson :  Ueber  den  Einfluss  des  Hals  sympathicus  auf  das 
Auge,  Graefe's  Archiv,  Bd.  Iv,.  Heft  1. 

Chipault :  Resec.  of  Cerv.  Sympathetic.  Internat.  Med.  Congress, 
Paris,  1900. 

Mullen :    Amer.    Medicine.    June    22,    1901. 

Williams  and  Shorter  :   Med.  News,  April  6,   1901. 

Gruening :  Discussion  in  N.  Y.  Acad.  of  Med.,  Ophthal.  Sec., 
Nov.  18,  1901. 

Altland :  Exstirpation  des  gang.  cerv.  sup.  nerv.  sympath.  bei 
glaukom,  Klin.  Monatsbl.  f.  Augenheilkunde,  February,  1902. 

Renaud :  Sympathectomy  in  Simple  Optic  Nerve  Atrophy :  a 
clinical  report,  St.  Louis  Med.  Review,  Feb.  1,  1902. 

20.  Archives    d'Ophthalmogie,     May,  1901. 


90 

Cutler  and  Gibson  :  Removal  of  Superior  Cervical  Ganglion  for 
Relief  of  Glaucoma,  case,  Annals  of  Surgery,  Phila.,  Sept.,  1902. 

Floor :  Fall  von  Syinpathicus  Resection  gegen  Glaukom,  Wiener 
Klin.  Woch..  No.  36.  1902. 

LaMotte :  New  Surgical  Treatment  of  Glaucoma,  Ophthalmic 
Record.  Chicago.  October.  1902 :  Denver  Medical  Times,  March, 
1903. 

Griinert :  Die  Behandlung  des  Glaucoms  durch  Entfernung  des 
oberen  Sympath.  Hals  Ganglion,  Archiv  f.  Augenheilkunde,  1900, 
vol.  xlii ;  Klin.  Monatsbl.  f.  Augenheilk.,  October,  1900. 

Cattaneo :  La  simpatectomia  cervicale  nella  cura  del  glaucoma, 
Bulletin  d.  Soc.  Med.  di  Bologna,  1900,  75,  xl,  526. 

Dor :  Glaucome  hemorrhag.-gueri  par  la  sympathectomie,  Lyon 
Medicale,  1900 :  Revue  generate  d'Ophthalmologie,  July,  1901 ; 
Archives  d'Ophthalmologie,  May,  1901. 

Marple :  Resection  of  the  Cervical  Sympathetic  Ganglion  In 
•Glaucoma,  N.  Y.  Medical  Record,  May  10,  1902. 

Lanphear :  Operation  on  Cerv.  Ganglia  of  Sympath.  for  Epilepsy, 
Glaucoma,  etc..  New  England  Med.  Monthly,  1900,  xix,  178. 

-tfuker :  THE  JOURNAL  Amer.  Med.  Assn..  1901,  p.  1588. 

Burghard :  Three  Cases  of  Removal  of  Sup.  Cerv.  Sympath. 
Ganglion.  British  Med.  Jour..  Oct.  20,  1900,  p.  1175. 

DeWecker  :  Valeur  de  1'Iridectomie  dans  le  Glaucome,  Archives 
d'Ophthalmologie.  May,  1901. 

Jayal :  Auto-Observation  de  Glaucome,  Annales  d'Oculistique, 
September.  1901. 

Neuschiiber :  Le  sympathique  et  la  tension  de  1'oeil,  Annali 
d'Ottalmologia.  xxv;ii,  1899. 

Mohr :  Beitrag.  zu  Exstirpation  des  ganglion  cerv.  sup.  bei 
Glaukom,  Klin.  Monatsbl.  f.  Augenh.,  1900,  s.  159. 

Schimanowski  :  Excision  of  Sup.  Cerv.  Ganglion  in  Glaukom. 
AVestnik  Ophthalmologi,  May- June,  1900.  (Translation.) 

Albertotti :  Annali  di  Ottalmologia,  xxix,  123. 

Angelucci :  La  riforma  medica,  No.  214. 

Rohmer :  Quelques  observations  sur  Sympathectomie  dans  Glau- 
come, Annales  d'Oculistique,  May,  1902.  p.  328. 

Campos :  Sur  la  th6orie  sympathique  du  Glaucome,  Archives 
d'Ophthalmologie,  T.  xviii.  1898. 

Demicherie :  Sympathectomie  dans  les  cas  de  Glaucome,  Annal. 
d'Oculistique.  T.  cxxi,  1899,  p.  188. 

Hertel :  Archiv.  f.  Ophthalmologie,  Bd.  xlix,  Abt.  2. 

Langendorff :  Klin.  Monatsbl.  f.  Augenh.,  xxxviii,  1899,  March, 
1900. 

Nicati :   Archives  d'Ophthalmologie.   T.   xx. 

Zimmermann :  Ophthalmolog.  Klinik,  iii,  No.  14,  1899. 

Weeks :  Cases  of  Simple  Chronic  Glaucoma  Treated  by  Resection 
of  the  Superior  Ganglion  of  the  Cervical  Sympathetic,  Transactions 
of  the  American  Ophthalmological  Society,  1902. 

Woodruff,  H.  W. :  Report  of  a  Case  of  the  Removal  of  the 
Superior  Cerv.  Sympathetic  Ganglion  for  Glaucoma,  Chicago  Medical 
Recorder.  July.  1901. 


IXFLUEXCE    OF    KESECTIOX    OF    THE    CEK- 
VICAL  SYMPATHETIC 

JX    OPTIC-XEUVE   ATROPHY,    HYDROPHTHALMOS    AND    EX- 
OPHTHALMIC  GOITER. 


JAMES  MOORES  BALL,  M.D. 

f'rofessor  of  Ophthalmology  in  the  St.  Louis  College  of  Physicians 
and  Surgeons. 

ST.    LOUIS. 


I.    SYMPATHETICECTOMY   IX   OPTIC-NERVE  ATROPHY. 

History. — Excision  of  the  cervical  portion  of  the  sym- 
pathetic nerve  for  the  relief  of  optic-nerve  atrophy  was 
proposed  and  executed  by  the  writer  in  1899.  (The 
date  of  the  first  operation  was  June  24.) 

Report  of  Cases. — A  report  of  this  case  was  included 
in  a  paper1  which  was  read  before  the  Ninth  Interna- 
tional Ophthalmologic  Congress,  in  1899.  From  that 
paper  I  now  quote : 

T.  J..  aged  46,  an  inmate  of  the  St.  Louis  City  Hospital,  a 
laborer,  was  admitted  on  account  of  blindness.  There  was  no 
"history  of  syphilis,  rheumatism  nor  any  systemic  disease.  The 
patient  was  of  limited  mentality.  Xo  history  of  his  family 
could  be  obtained.  He  claimed  to  have  had  good  health  all 
his  life,  with  the  exception  of  an  attack  of  malarial  fever  sev- 
eral years  ago.  The  patient  has  been  a  moderate  drinker  of 
alcoholic  beverages.  In  appearance  he  was  robust,  and  he  com- 
plained only  of  loss  of  vision,  which  in  the  left  eye  had  been 
failing  for  eleven  months,  in  the  right  for  seventeen  weeks  ac- 
cording to  his  statement.  Until  seventeen  weeks  before  this  time 
lie  could  see  enough  with  the  right  eye  to  get  around.  Since 
then  vision  had  steadily  declined  until  he  had  light  perception 
only — and  this  apparent  only  when  light  was  concentrated  on 
the  eye  by  the  ophthalmoscopic  mirror.  Vision  of  left  eye  =0. 

1.  Ball :  On  Removal  of  the  Cervical  Sympathetic  in  Certain 
Ocular  Diseases — Glaucoma  and  Optic  Nerve  Atrophy,  NeuviSme 
«?ongr£s  International  d'Ophtalmologie  d'Utrecht.  1899,  p.  551. 


92 

The  pupils  were  widely  dilated.  The  ophthalmoscope  showed 
in  the  right  eye  a  white  disc,  particularly  on  the  temporal 
side;  the  arteries  were  slightly  reduced  in  caliber,  veins  normal. 
There  was  shallow,  atrophic  cupping  of  the  nerve  head.  The 
retina  and  choroid  were  normal,  the  vitreous  and  lens  clear 
The  left  eye  showed  a  disc  of  a  dead  white  color  throughout 
the  whole  area,  arteries  very  small,  atrophic  excavation  pro- 
nounced, A'eins  reduced  in  caliber  and  choroid  normal.  The 
macula  was  not  visible  in  this  eye,  owing  to  the  much  reduced 
blood  supply.  The  vitreous  and  lens  were  clear.  Vision  \va- 
as  follows:  R.  E.  =  perception  of  concentrated  light.  L.  E. 
=0. 

Diagnosis. — R.  E.=  optic  nerve  atrophy.  L.  E.  =  complete 
atrophy  of  optic  nerve  and  retina. 

Treatment. — Resection  of  the  right  superior  cervical  gang- 
lion of  the  sympathetic  was  done.  The  operation  was  followed 
by  conjunctival  congestion,  lachrymation  and  contraction  of 
the  pupil,  slight  ptosis  and  hypotonia. 

No  appreciable  change  in  the  patient's  vision  followed,  and 
ophthalmoscopic  examination  made  two  weeks  after  operation 
.showed  no  change  in  the  appearance  of  the  fundus,  except  that 
a  cilioretinal  artery  in  the  upper  part  of  the  disc  had  doubled 
in  caliber. 

I  was  led  to  make  this  experimental  operation  for  several 
reasons:  1.  The  use  of  glonoin  is  often  followed  by  an  im- 
provement in  vision  in  cases  of  simple  atrophy  of  the  optic 
nerve.  2.  Glonoin  enlarges  the  retinal  vessels,  as  has  been- 
proved  by  ophthalmoscopic  examination.  3.  There  is  no  ques- 
tion that  in  glaucoma  simplex — a  disease  in  which  there  is  an 
atrophy  of  the  optic  nerve — improvement  in  vision  follow? 
sympatheticectomy.  4.  Excision  of  the  cervical  sympathetic  is 
followed  by  an  increase  in  the  blood  supply  of  the  orbital 
contents. 

My  second  case  of  sympatheticectomy  for  optic  nerve 
atrophy  occurred  in  the  summer  of  1900.  It  has  not 
been  reported,  for  the  reason  that  an  assistant  lost  the 
case  history.  The  result,  however,  was  all  that  could 
be  expected. 

The  patient  was  an  Irishman,  a  bartender  by  occupation. 
He  was  about  40  years  of  age.  For  several  months  the  visior 
of  both  eyes  had  steadily  declined.  Several  oculists  had  given 
him  medical  treatment  for  simple  optic-nerve  atrophy  without 
result.  The  poorer  eye  had  vision  equal  to  the  counting  of 
fingers  at  two  feet.  I  excised  the  superior  cervical  ganglion 
of  the  sympathetic  nerve  on  the  corresponding  side.  Vision 
steadily  increased  to  20/100.  The  patient  was  lost  sight  of. 
but  one  year  later  he  sent  word  ^hat  his  vision  was  excellent 
and  that  he  was  following  his  vocation. 


93 

I  regret  that  this  case  can  not  be  more  fully  described. 
My  third  case  of  atrophy  treated  by  sympatheticectomy 
occurred  in  1901. 

J.  H.,  aged  64  years,  a  native  of  New  York  City,  for  18 
years  had  been  a  sailor.  For  many  years  he  was  excessively 
addicted  to  the  use  of  alcohol  and  tobacco.  In  1888  he  con-, 
tracted  syphilis,  for  which  he  was  treated  for  two  months 
Vision  in  R.  E.  began  to  fail  in  1898;  in  L.  E.  in  1900.  He 
was  admitted  to  the  St.  Louis  City  Hospital  on  Jan.  29,  1901. 
The  hospital  record  shows  that  he  was  in  good  general  health. 
He  was  given  large  doses  of  mercury  and  iodids. 

Patient  came  under  my  care  on  March  1,  1901.  His  gen- 
eral condition  was  good.  Vision  of  R.  E.  =0;  of  L.  E.  = 
fingers  at  6  inches.  The  ophthalmoscope  showed  a  typical 
picture  of  simple  atrophy  of  the  optic  nerves.  Strychnia  in 
increasing  doses  was  ordered  and  was  continued  for  five  weeks 
without  benefit. 

On  April  11,  1901,  assisted  by  Dr.  R.  F.  Amyx,  I  excised  the 
left  superior  cervical  ganglion  of  the  sympathetic  nerve.  At 
this  time  the  right  eye  was  absolutely  blind;  with  the  left 
eye  fingers  could  be  counted  at  6  inches.  Tw6  days  after  the 
operation  he  counted  fingers  at  15  feet.  On  April  27  he  counted 
fingers  at  12  feet.  There  was  a  gradual  loss  of  vision,  until  at 
the  end  of  a  few  weeks  the  patient  was  in  the  same  condition 
as  before  operation. 

Cases  Reported  by  Other  Surgeons. — Suker2  per- 
formed a  bilateral  sympatheticectomy  in  a  case  of  bi- 
lateral simple  atrophy  of  the  optic  nerve.  Before  opera- 
tion the  visual  acuity  was  reduced  to  form  perception 
at  two  feet.  After  operation  the  hand  could  be  recog- 
nized at  six  feet.  Two  years  later  the  acuity  was  re- 
tained. 

Renaud3  has  reported  one  of  my  cases  and  two  of  his 
own.  In  January,  1900,  he  made  a  bilateral  sympa- 
theticectomy for  a  unilateral  optic-nerve  atrophy  which 
followed  an  attack  of  optic  neuritis  existing  four  months 
previously.  Vision  was  reduced  to  the  counting  of  fin- 
gers at  six  feet.  Four  and  one-half  months  later  the 
patient  could  count  fingers  at  eighteen  feet  (V.— 
20/100).  Renaud's  other  case,  which  was  one  of  simple 
atrophy,  showed  in  two  months  an  improvement  in 
vision  from  10/200  to  20/50.  Renaud4  has  operated  on 
another  case  without  success. 

2.  Snker :  New  York  Medical  Journal,  Feb.  24,  1900. 

3.  Renaud :  St.  Louis  Medical   Review,   Feb.  1,   1902. 

4.  Renaud :  Personal  communication,   April  30,  1903. 


94 

E.  Gruening3  of  Xe\v  York  has  had  one  case  which 
is  best  described  in  his  own  words : 

My  experience  with  the  excision  of  the  superior  cervical 
sympathetic  ganglion  in  atrophy  of  the  optic  nerve  is  limited 
to  one  case.  It  concerned  a  man,  33  years  of  age,  who  had 
contracted  syphilis  fifteen  years  previously.  When  I  saw 
him  in  1902  he  was  entirely  blind  as  regards  his  left  eye,  but 
saw  well  centrally  with  his  right.  Here  the  field  was  tele 
scopic,  measuring  t°n  degrees  in  diameter.  Vision  was  ^0/30. 
He  read  J.  1.  Pupils  small.  Argyll-Robertson  reaction — 
knee  reflexes  lost  entirely — a  case  of  post-syphilitic  tabes  with 
atrophy  of  the  nerves.  The  ganglion  was  removed  on  the  right 
side.  Vision  became  worse  and  three  months  later  the  man 
was  totally  blind. 

Thus,  of  8  cases  in  which  sympatheticectomy  was  per- 
formed by  optic-nerve  atrophy,  there  were  4  failures  and 
4  improvements. 

Should  Bilateral  Resection  be  Done  for  Unilateral 
Atrophy? — At -the  present  time  it  is  impossible  to  an- 
swer this  question  ex  cathedra.  Renaud  states  that  "the 
superior  cervical  ganglion  should  be  removed  on  both 
sides  in  all  cases,  whether  the  affection  be  unilateral  or 
bilateral."  It  is  possible  that  the  unexcised  ganglion 
exerts  an  influence  on  the  opposite  eye,  the  anatomic- 
path  probably  being  through  anastomosis  of  fibers  in 
the  carotid  plexus. 

II.  TREATMENT  OF  HYDBOPITTHALMOS  BY  OPERATIONS  OX 

THE   SYMPATHETIC   NERVE. 

Pew  cases  of  congenital  hydrophthalmos  have  been 
treated  by  operations  made  on  the  cervical  sympathetic. 
Palmtag  and  Kolle  removed  the  superior  ganglion,  while 
Schwilke  and  Mader  performed  sympatneticotomy. 
These  four  patients  were  8,  2~y2,  4y2  and  9  years  of  age. 
respectively.  The  tension  was  uninfluenced,  and  the 
vision,  so  far  as  could  be  determined  in  such  young  sub- 
jects, was  unchanged.  The  operations,  consequently, 
were  valueless.  Grunert6  states  that  the  general  health 
of  these  children  was  not  influenced  by  these  procedures. 

III.  OPERATIONS  ON  THE  SYMPATHETIC  NERVE  FOR  THE 

RELIEF  OF  EXOPHTHALMIC  GOITER. 

Exophthalmic  goiter  is  a   disease  belonging  to  the 

5.  Gruening :  Personal  communication.  March  23,  1003. 

6.  Grunert :  Die  Behandlung  des  Glaucoms  durch  Sympatheticus- 
resection,     Bericht    xxviii.     Versammlung    der    Ophthalmologischen 
Gesellschaft   (Heidelberg,   1900),  Wiesbaden.   1901.  p.  19. 


domains   of   the   ophthalmologist,   neurologist,    surgeon 
and  general  practitioner. 

Without  desiring  to  enter  into  a  resume  of  the  litera- 
ture of  the  last  ten  years  or  to  excite  a  discussion  on  the 
nature  of  the  disease,  I  will  remark  that  there  are  good 
reasons  for  dividing  cases  of  exophthalmic  goiter  into 
three  groups,  as  advocated  by  Lanphear  :7 

1.  Those  dependent  on  changes  in  the  central  nerv- 
ous system,  in  which  no  operative  measures  can  be  of 
benefit. 

2.  Those  due  to  disease  of  the  cervical  sympathetic, 
in  which  excision  of  the  ganglia  may  give  relief. 

3.  Those  arising  from  excessive  thyroid  secretion,  in 
which  thyroidectomy  may  cure. 

Granting  that  a  certain  percentage  of  cases  will  re- 
cover spontaneously;  that  some  will  show  great  im- 
provement without  treatment;  that  others  will  recover 
under  the  rest  cure,  or  by  change  of  climate,  or  by  the 
influence  of  pregnancy;  and  that  some  will  recover  un- 
der the  use  of  such  diverse  measures  as  cauterization  of 
hypertrophied  inferior  turbinatecl  bodies,  the  removal 
of  nasal  polypi,  the  painting  of  the  thyroid  region  with 
collodion,  the  use  of  the  galvanic  current,  or  of  the 
faradic  current  the  administration  of  iron,  quinin.  bella- 
donna, digitalis,  strophanthus,  hydroiodic  acid,  ergot,, 
spartein,  salicylate  of  soda,  corbolozate  of  ammonia, 
thyroid  extract,  etc.,  there  will  still  remain  a  not  incon- 
siderable number  of  cases  in  which  surgical  intervention 
will  be  required. 

Before  resorting  to  any  form  of  operation  it  is  well 
to  remember  ( 1 )  that  no  surgical  procedure  will  cure  all 
cases,  and  (2)  that  sudden  death  has  not  infrequently  fol- 
lowed carefully  planned  and  skilfully  executed  opera- 
tions made  on  this  class  of  patients.  Harris8  has  re- 
ported the  death  of  a  lady  who,  having  exophthalmic 
goiter,  was  operated  on  for  the  removal  of  a  non-ma- 
lignant mammary  tumor  and  died  suddenly.  Lance- 
reaux9  has  called  attention  to  the  danger  of  sudden  death 
after  goiter  operations,  and  has  commented  on  the  great 
value  of  morphin  in  such  patients.  Warren10  has  ad- 

7.  Lanphear :    St.    Louis    Medical    and    Surgical    Journal.    Majv 
1900. 

8.  Harris  :   British    Medical   Journal,   May   4,    1901. 

9.  Lancereaux  :  La  Semaine  Medicale,  Paris,   January.   1894. 
10.  Warren  :  American  Year-book  of  Medicine  and  Surgery.  Phila- 
delphia, 1896,  p.  289. 


96 

vanced  the  idea  that  during  the  operation  a  toxic  sub- 
stance from  the  thyroid  may  gain  admission  to  the  cir- 
culation and  cause  death.  Booth11  states  that,  owing  to 
the  care  which  is  now  exercised  in  the  removal  of  the 
diseased  gland,  this  theory  is  no  longer  tenable. 

Patients  with  simple  goiter  often  do  badly  under  gen- 
eral anesthetics.  In  addition  to  the  dangers  pertaining 
to  such  cases,  the  patients  with  exophthalmic  goiter 
must  face  other  dangers.  The  chance  of  death  from 
chloroform,  according  to  Halstead,12  is  much  increased 
by  the  degenerated  heart  muscle  and  the  increased  ir- 
ritability of  the  heart  centers;  and  in  the  retrosternal 
and  retroclavicular  forms  of  goiter  ether  anesthesia  is 
equally  dangerous.  Fiitterer  has  shown  that  collapse  of 
the  trachea,  which  may  occur  after  operation  for  any 
form  of  goiter,  is  due  to  mucoid  degeneration  of  the 
cartilaginous  tracheal  rings.  The  patient  makes  a  vio- 
lent inspiratory  effort,  collapse  of  the  trachea  results  and 
death  occurs  by  asphyxia.  Because  of  these  dangers, 
not  a  few  surgeons,  including  Kocher,13  believe  that 
goiter  operations  should  be  performed  under  local  anes- 
thesia. 

CLASSIFICATION  OF   OPERATIONS   ON   THE   CERVICAL   POR- 
TION  OF  THE  SYMPATHETIC   NERVE. 

These  procedures,  which  have  been  tried  in  the  treat- 
ment of  exophthalmic  goiter,  are: 

1.  Simple  division  of  the  cervical  sympathetic  (first 
suggested  by  Edmunds14  in  cases  in  which  perforation  of 
the  cornea  is  threatened,  and  first  performed  by  Ja- 
boulay) . 

2.  Ablation  of  the  cervical  sympathetic,  consisting  in 
the  torsion  and  ablation  of  the  nerve  by  means  of  artery 
forceps   passed   through   a   small   incision    (Jaboulay's 
procedure). 

3.  Simple    stretching    of    the    cervical    sympathetic 
(first  practiced  by  Jaboulay). 

4.  Partial  resection  of  the  cervical  sympathetic  (first 
performed  by  Alexander  of  Edinburgh,  in  1889,  for  the 

11.  Booth :    Radical    Cure    of    Exophthalmic    Goiter,    Journal    of 
Nervous  and  Mental   Diseases,    September,   1902,   p.   521. 

12.  Halstead :  Pathogenesis  and  Surgical  Treatment  of  Exophthal- 
mic  Goiter,  Medicine,  September,  1902. 

13.  Kocher :  Sixty-fourth  Annual  Meeting  of  the  British  Medical 
Association,  Aug.  6,  1898. 

14.  Edmunds :   Lancet,   May   25,    1895. 


97 

cure  of  epilepsy,  and  limited  by  him  to  the  removal 
of  the  superior  ganglion) . 

5.  Partial  and  extensive  resection    (excision  of  the 
upper  and  middle  ganglia  with  the  intervening  strand). 

6.  Total  resection  of  the  cervical  sympathetic    (re- 
moval of  all  three  ganglia  and  the  nerve  strand).    This 
was  first  performed  by  Jonnesco. 

7.  Thyroidectomy  with  partial  and  extensive  resec- 
tion of  the  cervical  sympathetic,  was  suggested  by  the 
writer  in  1901,  in  a  case  under  the  care  of  Dr.  F.  Eob- 
ert  Boyd,  and  was  practiced  by  Dr.  J.  W.  Smith  of  St. 
Louis. 

The  comparative  value  and  mortality  of  exophthalmic 
goiter  operations  can  not  be  definitely  determined,  be- 
cause (1)  many  cases  ending  in  death  have  not  been 
reported,  and  (2)  not  all  of  the  published  statistics  are 
reliable,  there  being  in  some  of  the  published  reports  an 
absence  of  differentiation  between  the  various  procedures 
practiced  on  the  sympathetic  nerve. 

1.  Thyroidectomy. — The  general  mortality  of  this 
operation  is  7  per  cent.  (Booth15),  while  the  percentage 
of  death  in  cases  of  exophthalmic  goiter  is  much  higher. 
Rehn16  of  Frankfurt,  who  collected  177  cases,  places  it 
at  13.6  per  cent.  Tricomini17  (72  cases)  places  the 
mortality  at  15  per  cent.,  and  Sorgo18  (172  cases)  at 
14  per  cent.  Jonnesco19  claims  that  the  mortality  is 
over  17  per  cent.,  and  rejects  the  operation  because  of 
the  high  death  rate.  Kocher's20  recent  statistics  are 
very  favorable.  He  made  59  operations:  45  cases  (76 
per  cent.)  were  cured;  8  (14  per  cent.)  were  improved; 
2  (3.3  per  cent.)  were  slightly  improved,  and  4  (6.7 
per  cent.)  died.  When  we  remember  that  many  of  the 
unsuccessful  cases  have  not  been  reported,  it  seems  rea- 
sonable to  place  the  mortality  of  thyroidectomy  for  ex- 
ophthalmic goiter  at  20  per  cent.  Rehn21  claims  57.6 
per  cent,  of  cures  for  thyroidectomy.  Jonnesco 
claims  that  the  reported  successes  of  this  operation  have 
been  largely  among  those  atypical  cases  in  which  the 
goiter  long  preceded  the  ocular  and  cardiac  symptoms. 

15.  Booth:  Medical  Record.  Aug.  13,  1898. 

16.  Rehn:  Munchener  Medizinische  Wochenschrift,  Oct.  10,  1899. 

17.  Tricomini :    II    Policlinico,    Roma,    1896. 

18.  Sorgo :  Centralblatt  fur  Grenzgeb.  der  Medicin,  No.  1,  p.  329. 

19.  Jonnesco :   Revue  Chirurgicale,   November,    1897,  supplement. 

20.  Keener:    Mittheilungen   aus   dem   Grenzgebieten  der  Medicin 
und  Chirurgie,  1902. 

21.  Rehn :  Munchener  Medizinische  Wochenschrift,  Oct.  10,  1899. 
7 


98 

Doyon,  is  a  strong  advocate  of  thyroidectomy,  and  would 
resect  the  sympathetic  only  after  failure  of  the  former 
operation. 

The  danger  of  sudden  death  after  thyroidectomy  is 
emphasized  by  Starr's  report.  Of  190  cases,  not  less 
than  23  died  suddenly.  Surrel,22  who  has  recently  dis- 
cussed this  subject,  attributes  these  accidents  to  either 
an  acute  thyroidin  intoxication,  or  to  a  sudden  stoppage 
of  the  heart's  action.  The  latter  is  supposed  to  be 
caused  by  the  traction  which,  during  the  operation,  is 
exerted  on  the  nerves  of  the  thyroid  gland,  which  are 
intimately  associated  with  the  vagus  nerve.23  After 
thyroidectomy  a  number  of  complications  have  been  ob- 
served, such  as  a  rise  of  temperature,  which  is  accom- 
panied by  a  sensation  of  heaviness,  dyspnea,  tachycar- 
dia and  vomiting.  Hemorrhages,  tetany  and  vocal  dis- 
turbances, dysphagia  and  bronchopneumonia  have  also 
been  observed. 

2.  Ligation    of    the    thyroid    arteries,    according    to 
Rehn,24  gives  a  mortality  of  28.6  per  cent. ;  2.4  per  cent. 
were  cured,  and  50  per  cent,  were  improved.     Regard- 
ing this,  Balacesu25  says :     "The  method  of  ligaturing 
the  thyroid  arteries  has  been  the  first  to  be  abandoned 
(among  operations  attacking  the  thyroid  gland),  be- 
cause in  nearly  all  cases  the  disease  recurred  in  a  few 
months  after  operation.    Secondly,  the  execution  of  this 
operation  was  difficult  where  the  thyroid  was  very  large, 
especially  in  cases  in  which  its  relations  to  surrounding- 
tissues   were   altered;   or   it   predisposed   to   secondary 
hemorrhages  on  account  of  the  fragility  of  the  vessels." 
Kocher,  Kopp  and  Rehn  have  recorded  cases  in  which 
this  operation  was  followed  by  tetany. 

3.  Exotliyropexy,  which  was  first  done  by  Poncet  and 
Jaboulay,  consists  in  exposing  the  thyroid  gland,  and 
suturing  it  in  the  wound,  where  it  is  left  exposed,  in  the 
hop^  that  atrophy  will  occur.    This  operation  has  been 
abandoned  by  Poncet,  because  of  the  high  mortality 
(23  per  cent.)  and  the  frequent  recurrence  of  Basedow's 
disease  after  this  procedure. 

Simple  Section  of  the  Sympathetic  Nerve. — Jabou- 

22.  Surrel :  Des   accidents  qui  peuvent  compliquer  1'intervention 
chirurgicale  dans  le  goitre  exophtalmique,   Thesfe  de  Paris,   1897. 

23.  De  Cyon  :  Acad.  des  Sciences,  1897,  Juin. 

24.  Rehn  :  Miinchener  Medizinische  Wochenschrift,  Oct.  10,  1899. 

25.  Balacesu :    Archiv   fiir   Klinische    Chirurgie,    vol.    Ixvii,    1902. 


99 

lay26  performed  bilateral  section  in  6  cases  and  the  uni- 
lateral operation  in  2  cases.  He  records  2  cures,  5  im- 
proved cases  and  1  death,  which  occurred  18  months 
after  operation — a  mortality  of  12.5  per  cent.  In  all  of 
these  patients  the  exophthalmos  was  influenced  favora- 
bly after  the  first  day;  the  thyroid  enlargement  dis- 
appeared slowly,  while  the  tachycardia  was  scarcely 
influenced  by  the  operation.  He  proposes  that  in  cases 
in  which  the  tachycardia  is  pronounced  the  inferior 
cervical  ganglion  shall  be  excised.  Balacesu27  claims 
that  simple  section  influences  the  exophthalmos  and 
thyroid  enlargement  but  little,  and  the  tachycardia  not 
at  all.  Pean28  pronounces  the  operation  resultless  and 
unnecessary.  He  advocates  thyroidectomy.  Gayet29  has 
stated  that  simple  section  powerfully  influences  the  triad 
of  symptoms,  and  this  effect  is  permanent.  It  must  be 
remembered  that  Gayet's  article  appeared  in  1896,  while 
that  of  Balacesu  was  published  in  1902. 

5.  Stretching  of  the  Cervical  Sympathetic. — In  the 
only  ( Jaboulay's)  case  in  which  this  operation  was  per- 
formed the  tachycardia  was   markedly  increased,   the 
pulse  ranging  from  110  to  130  two  weeks  after  the  oper- 
ation.     The    exophthalmos    and    tlryroid    enlargement 
were  uninfluenced. 

6.  Stretching  of  the  pneumogastric   nerve    has    been 
tried  by  Jaboulay30  in  cases  of  exophthalmic  goiter  with 
severe  cough.    It  is  said  to  arrest  the  laryngeal  spasms. 
This  procedure  must  be  regarded  as  dangerous  and  with- 
out curative  value. 

7.  Ablation  of  the    cervical   sympathetic   has   been 
abandoned. 

8.  Partial  Resection  (Kemoval  of  the  Superior  Gang- 
lion) and  Partial  and  Extensive  Resection  (Removal  of 
the  Superior  and  Middle  Ganglia  with  the  Intervening 
Strand. — These  procedures  have  gained  an  established 
position  among  exophthalmic  goiter  operations.     Bal- 
acesu31 reports  27  cases  which  were  treated  by  partial  re- 
section, and  were  observed  for  periods  varying  from 
1  to  4  years.    In  all  of  these  cases  there  was  rapid  and 

26.  Jaboulay :    Chirurgie   du   Grand   Sympathetique   et   du    Corps 
Thyroide,  p.  79,  1900. 

27.  Balacesu  :  Archiv  fur  Klinische  Chirurgie.  vol.  Ixvii,  1902. 

28.  Pean  :  Bull.  Acad.  de  Med.,  Tome  iii,  p.  31,  1897. 

29.  Gayet:    Lyon    MSdicale,    No.    30,    1896. 

30.  Jaboulay:   Lyon  M6dicale,    April,  1898. 

31.  Balacesu  :  Archiv  fur  Klinische  Chirurgie,  vol.  Ixvii,  1902. 


100 

pronounced  improvement.  The  exophthalmos  disap- 
peared within  the  first  few  days,  the  thyroid  diminished 
in  the  first  8  days,  but  the  tachycardia  persisted,  the 
pulse  ranging  from  110  to  120.  The  palpitation  did 
not  return,  and  the  facial  expression  was  much  changed 
for  the  better.  After  a  time,  the  tachycardia  showed  a 
tendency  to  decrease,  but  never  was  as  pronouncedly 
influenced  as  were  the  other  Basedow  symptoms.  In  this 
series  of  27  cases  there  were  9  cures,  11  improvements, 
2  uncured  cases  and  5  deaths,  none  of  which  could  be 
attributed  to  the  operation.  The  mortality  of  these  pro- 
cedures is  small,  probably  less  than  5  per  cent.  Sudden 
death,  however,  has  occurred  after  partial  resection. 
One  such  case,  which  was  operated  bilaterally  by  Ber- 
nays  and  Simpson32  of  St.  Louis,  died  of  heart  failure 
on  the  llth  day.  That  partial  resection  is  not  always 
curative  is  shown  by  a  case  recorded  by  Chauffaud  and 
Quenu,33  who  removed  the  superior  ganglia  without  in- 
fluencing the  exophthalmos  and  goiter.  It  seems  rea- 
sonable to  concede  (1)  that  partial  resection  is  the  oper- 
ation of  choice  in  those  cases  of  exophthalmic  goiter  in 
which  the  ocular  and  thyroid  are  more  prominent  than 
the  cardiac  symptoms;  (2)  that  the  bilateral  resection 
should  be  made,  but  not  at  the  same  sitting,  an  interval 
of  2  or  3  weeks  being  advisable;  (3)  that  the  mortality 
is  low. 

9.  Total  bilateral  resection  is  the  procedure  of  choice 
among  the  sympathetic  operations.  Of  19  cases  which 
are  reported  by  Balacesu34  as  occurring  in  the  practice  of 
Jonnesco,  Soulie,  Faure,  Peugnecz  and  Depage,35  in  14, 
after  the  second  day  after  operation,  the  Basedow  symp- 
toms disappeared  one  after  another.  This  improvement 
continued  daily  until  cure  was  complete.  This  report 
is  verified  by  the  experience  of  Halstead36  and  Wither- 
spoon.37  Halstead,  writing  four  weeks  after  total  bi- 
lateral resection,  says:  "The  patient's  exophthalmos 
has  gieatly  improved;  the  pulse  is  better,  the  tremor  and 
general  nervous  condition  are  improved/'  Witherspoon, 
in  1899,  was  consulted  by  a  woman  aged  59  years,  who 

32.  Bernays    and    Simpson :    Personal    communication,    April    15, 
1903. 

33.  Chauffaud  et  Qu§nu :  Presse  Medicale,  July  3,  1897. 

34.  Balacesu :  Archiv  fur  Klinische  Chirurgie,  1902. 

35.  DSpage :  Societe  Royale  des  Sciences  Medicates  et  Naturelles 
Bruxelles.   1898. 

36.  Halstead :    Personal   communication,   April    14,    1903. 

37.  Witherspoon :  Personal  communication,  April  15,  1903. 


101 

showed  moderate  exophthalmos,  marked  enlargement  of 
the  right  thyroid  lobe,  and  a  pulse  rate  varying  from 
130  to  150.  She  heard  strange  noises  and  had  ideas  of 
persecution;  the  skin  was  moist,  and  the  urine  showed 
casts  and  albumin.  The  diagnosis  was  chronic  intersti- 
tial nephritis,  associated  with  Graves'  disease.  Believing 
that  in  her  general  condition  thyroidectomy  was  con- 
traindicated,  Witherspoon  advised  sympatheticectomy. 
On  September  10  the  operation  was  made  on  the  right 
side.  Eleven  days  later  the  left  side  was  operated  on. 
After  the  second  operation  the  pulse  showed  improve- 
ment in  quality  and  rate,  the  exophthalmos  and  enlarge- 
ment of  the  thyroid  almost  completely  disappeared,  and 
her  mental  condition  improved.  In  December  she  went 
on  a  visit  to  the  countr}r.  In  the  following  February, 
while  riding,  she  became  chilled  and  died  two  hours 
afterward.  Up  to  the  present  time  no  deaths  have  been 
directly  attributed  to  the  total  excision  of  the  cervical 
sympathetic.  The  results  are  63.8  per  cent,  of  cures; 
18.1  per  cent,  of  improvements;  18.1  per  cent,  of  fail- 
ures, and  no  deaths. 

10.  Thyroidectomy  with  partial  resection  of  the  cer- 
vical sympathetic  was  performed  on  a  patient  of  Dr.  F. 
Eobert  Boyd  by  Dr.  J.  W.  Smith  and  myself.  The  pa- 
tient nearly  died  on  the  table  from  hemorrhage  following 
the  slipping  of  a  ligature.  She  expired  suddenly  on  the 
third  day.  The  temperature  rose  suddenly  and  the 
pulse  became  too  frequent  to  be  counted. 

The  failure  of  thyroidectomy  to  relieve  the  exophthal- 
mos of  Basedow's  disease  was  remarked  on  by  Stevenson 
and  Shears.38  In  the  case  of  a  woman,  aged  25  years, 
from  whom  the  right  lobe  of  the  thyroid  had  been  re- 
moved 4  years  previously,  while  the  general  symptoms 
were  improved  greatly,  the  exophthalmos  had  steadily 
increased.  It  is  possible  that  cases  presenting  marked 
exophthalmos  and  thyroid  enlargement  without  much 
tachycardia  may  be  cured  by  thyroidectomy,  combined 
with  resection  of  the  superior  cervical  ganglion. 

CONCLUSIONS. 

1.  Excision  of  the  superior  cervical  ganglion  of  the 
sympathetic  nerve  is  worthy  of  a  trial  in  those  cases  of 
simple  atrophy  of  the  optic  nerve  which  resist  measures 
less  heroic. 

38.  British  Medical  Journal,  Jan.  25.  1902. 


102 

2.  It  is  yet  impossible  to  say  whether  the  bilateral 
operation  is  advisable  in  unilateral  optic-nerve  atrophy. 

3.  The    value    of    sympathetieectomy    in    congenital 
hydrophthalmos  has  not  been  demonstrated. 

4.  In  exophthalmic  goiter,,  complete  excision  of  the 
cervical  sympathetic  is  followed  by  a  larger  percentage 
of  cures  than  is  any  other  procedure.  Thus  far  no  deaths 
have  been  recorded.     The  number  of  operations,  how- 
ever, is  small  and  final  conclusions  can  be  announced 
only  after  a  large  number  of  cases  shall  have  been  treated 
by  this  method. 

3509  Franklin  Avenue. 


PATHOLOGY  OF  THE  CEEVICAL  SYMPA- 
THETIC. 


JOHN  E.  WEEKS,  M.D. 

ISTEW   YORK. 


The  departure  from  the  normal  in  the  cervical  sym- 
pathetic may  be  classed  under  two  heads,  namely,  irri- 
tation and  paralysis. 

1.  The  symptoms  of  irritation  are:  (a)  mydriasis,  due 
to  spasm  of  the  dilator  pupilke;  (b)  exophthalmus,  said 
to  be  due  to  contraction  of  the  smooth  muscular  fibers 
of  the  orbit  (Miiller's)  ;  (c)  widening  of  the  palpebral 
fissure  by  tonic  contraction  of  Miiller's  muscle;  (d) 
contraction  of  the  walls  of  the  vessels  of  the  head,  face 
and  neck,  including  pallor  of  the  skin,  frequently  with 
an  increase  in  the  amount  of  perspiration;  (e)  accelera- 
tion of  the  heart  beat. 

According  to  Xicati,1  paralysis  of  the  cervical 
sympathetic  may  be  divided  into  two  stages : 

First  Stage. —  (a)  Contraction  of  the  pupil,  (b)  nar- 
rowing of  the  palpebral  fissure  (ptosis),  (c)  decrease 
of  the  tension  of  the  globe,  (d)  increased  lachrymation, 
(e)  injection  of  the  ocular  conjunctiva,  and,  in  many 
cases,  (f)  slight  exophthalmus.  There  is  also  conges- 
tion of  the  corresponding  side  of  the  face,  anidrosis  in 
the  greater  number  of  cases,  sometimes  hyperidrosis ; 
also  acceleration  of  the  heart  action  in  a  minority  of  the 
cases. 

Second  Stage. — The  ptosis  remains.  The  miosis  per- 
sists for  some  months.  The  miosis,  consequent  on  re- 
moving the  stellate  ganglion  in  animals,  is  recovered 
from  in  two  to  three  months.2  The  tension  of  the  eye- 
ball becomes  normal  after  some  weeks  or  months,  grad- 

1.  Nicati,    La   paralysie    du    nerf   sympathetique   cervical,    Lau- 
sanne, 1873. 

2.  Onuf  and  Collins,   Arch,    of  Neur.   and   Psych.,   vol.   iii,   Nos. 
1  and  2. 


104 

ually  becoming  less  pronounced.  What  may  be  termed 
the  vasomotor  disturbances  disappear  in  a  relatively 
short  time.  In  exceptional  cases,  atrophy  of  the  tissues 
of  the  corresponding  side  of  the  face  follows. 

Cases  of  irritation  of  the  cervical  sympathetic  are  not 
common.  They  have  been  observed  as  being  due  to 
abscess  in  the  neck;3  pressure  of  tumors,  as  malignant 
growths,  cystic  goiter,4  with  exophthalmus ;  thoracic 
aneurism;5  injuries  to  the  neck;6  injuries  to  the  spinal 
cord,  between  the  fifth  cervical  and  third  dorsal  verte- 
brae.7 

Irritation  symptoms  may  pass  over  to  symptoms  of 
paralysis  and  again  return  to  those  of  irritation,  due  to 
irregular  pressure.  Cystic  growths  are  most  apt  to  pro- 
duce these  phenomena.  In  consulting  the  literature  on 
affections  of  the  cervical  sympathetic,  the  writer  has 
studied  the  reported  cases  of  irritation  of  this  portion 
of  the  sympathetic  nervous  system  for  the  purpose  of 
ascertaining  if  any  of  the  patients  suffered  from  glau- 
coma. Quite  a  full  list  of  the  reported  cases  of  this  na- 
ture is  given  by  Lloyd.8  In  none  of  the  histories  of  such 
cases  is  mention  made  of  glaucoma  as  a  complication. 

Paralysis  of  the  cervical  sympathetic  may  be  due  to 
the  pressure  of  tumors,  glandular  swellings,9  malignant 
neoplasms,10  cicatrices  in  the  neck,  aneurism,11  abscess,12 
wounds  of  the  neck,13  injuries  to  the  brachial  plexus  in- 
volving the  sympathetic,  diseases  and  injuries  affecting 
the  spinal  cord,  spinal  caries,  various  pulmonary  af- 
fections; paralysis  of  the  cervical  sympathetic  also  ap- 
parently occurs  idiopathically. 

Tumors  originating  in  the  sympathetic  and  interfer- 
ing with  its  function  are  extremely  rare.  A  case  of 
fibrosarcoma  of  the  cervical  sympathetic  is  reported  by 
Abbe/4  and  he  refers  to  cases  reported  by  Paget,  Prud"- 

3.  Althaus,  Med.  Chir.  Trans.,  vol.  xli,  p.  398. 

4.  Bemere,  Wurtzburger  med.  Zeitschr.,  1862,  bd.  iii,  S.  262. 

5.  Flint,  "Clinical  Medicine"  ;  Walshe,  "Diseases  of  the  Heart." 

6.  Seeligmuiler,   Arch.  £.  Psych.,  bd.  v.,  S.  835. 

7.  Rosenthal.  "Diseases  of  the  Nervous  System,"  p.  216. 

8.  "Twentieth  Century  Practice  of  Medicine,"  vol.  xi.,  p.  457. 

9.  Frankel,  Berl.  klin.  Woch.,  1875,  No.  3. 

10.  Verneuil,  Gaz.  des  hSpitaux,  April  1,  1864. 

11.  Gairdner,  Edinburgh  Med.  Jour.,  1855,  p.  143. 

12.  Jewell,  Chi.  Jour,  of  Mental  Dis.,  1874.  p.  15. 

13.  Weir    Mitchell,    "Gunshot    Wounds    and    Other    Injuries    of 
Nerves,"   Phila..  1864. 

14.  Annals  of  Surgery,  April,  1898. 


105 

den.,  Virchow,  Satterthwaite  and  Reynolds  of  neuro- 
fibromata  affecting  the  sympathetic. 

Of  the  symptoms  said  to  be  due  to  abnormal  condi- 
tions of  the  cervical  sympathetic  and  the  consequent  in- 
fluence on  the  vessels,  migraine  may  be  mentioned.  This 
may  be  preceded  or  accompanied  by  disturbances  of 
vision,  (a)  periodic  hemianopsia,  (b)  scintillating 
scotoma,  (c)  monolateral  transient  amaurosis,  and  (d) 
monolateral  photophobia.  Accompanying  migraine  we 
may  also  have  flushing  of  one  side  of  the  face,  anidrosis 
or  hyperidrosis,  with  narrowing  of  the  palpebral  fissures 
and  moderate  miosis. 

The  affections  of  the  eye,  supposed  to  be  caused  in 
greater  part  by  abnormal  conditions  of  the  cervical  sym- 
pathetic, are  glaucoma  and  exophthalmic  goiter.  It  is 
not  the  province  of  this  article  to  enter  into  a  discussion 
of  the  relation  of  the  cervical  sympathetic  to  these  dis- 
eases further  than  to  inquire  into  the  changes,  if  any, 
that  have  been  observed  in  the  tissues  of  the  cervical 
sympathetic  occurring  in  individuals  affected  by  these 
diseases. 

THE  GANGLIA  OF  THE  CERVICAL  SYMPATHETIC. 

The  ganglia  are  surrounded  by  a  thin,  firm,  adherent 
covering  of  connective  tissue  which  sends  prolongations 
into  the  ganglia,  dividing  them  into  compartments  of 
various  sizes  and  serving  as  a  supporting  structure.  A 
delicate  capsule,  composed  of  a  single  layer  of  cells  bear- 
ing nuclei,  surrounds  each  ganglion  cell.  The  ganglion 
cells  have  an  average  diameter  of  20  microns,  but  vary 
from  13  to  40  microns:  The  ganglion  cells  possess  one  to 
three  processes,  one  of  which  is  an  axon.  The  cells  are 
made  up  of  a  protoplasmic  body  containing  a  nucleus  and 
nucleolus.  Many  of  the  cells  contain  a  greater  or  less 
number  of  pigment  granules.  The  ganglia  contain 
numerous  nerve  fibers,  only  a  few  of  which  are  medul- 
lated.  The  blood  vessels  are  small  and  not  numerous. 

The  nerve-trunk  resembles  the  ganglia,  except  that  it 
contains  no  ganglion  cells,  and  apparently  contains  a 
greater  proportion  of  medullated  nerve-fibers. 

PATHOLOGIC  CHANGES. 

The  writer  has  little  doubt  that  the  ganglia  of  the 
cervical  sympathetic  in  the  aged  undergo  degenerative 
changes  to  some  degree.  It  is  certain  that  these  ganglia 


10G 

as  examined  in  the  dead-house  vary  much  in  size  and 
appearance. 

Hale  White  found  in  examining  33  semilunar  ganglia, 
taken  from  persons  dying  from  different  causes,  that 
most  of  them  showed  degenerative  changes  (Onuf  and 
Collins). 

Gustav  Kicke15  reports  a  case  presenting  symptoms  of 
irritation  of  the  cervical  sympathetic.  Autopsy  showed 
round-cell  infiltration  and1  small  hemorrhages  in  the 
superior  cervical  ganglion  of  the  affected  side.  He 
thinks  that  paralysis  of  the  vasomotor  fibers  and  irrita- 
tion of  the  oculopupillary  fibers  occurred. 

Petrow16  describes  changes  occurring  in  the  sympa- 
thetic in  constitutional  syphilis.  In  twelve  cases  which 
he  examined  he  found  distinct  alterations  in  the  nerve 
elements  and  in  the  interstitial  connective  tissue,  hyper- 
plasia  of  the  latter  being  apparent.  There  was  pigment 
and  colloid  degeneration  in  the  nerve-cells,  alterations  in 
the  cells  of  the  sheaths  of  the  ganglion  cells  consisting 
of  increase  in  size  and  proliferation.  The  endothelial 
cells  showed  secondary  fatty  degeneration. 

Pio  Foa  (Suir  anatomia  del  gran  simpatico)  wrote 
concerning  some  changes  he  had  observed  in  the  sym- 
pathetic in  various  diseases.  These  were  found 
chiefly  in  the  cervical  and  abdominal  ganglia, 
and  consisted  sometimes  of  simple  or  fibrous  atrophy, 
at  other  times  of  hyperemia,  sclerosis,  pigmentary  and 
fatty  infiltration,  amyloid  degeneration,  accumulation 
of  colorless  blood-corpuscles  and  the  presence  of  micro- 
cocci  in  the  blood  vessels  of  the  ganglia.  These  altera- 
tions are  well  marked  in  syphilis,  leukemia,  pellagra, 
tuberculosis  and  infectious  diseases. 

Mention  should  be  made  of  two  reports  by  Koster17 
on  the  state  of  the  cervical  sympathetic  in  persons  who 
had  died  suddenly  from  sunstroke.  In  one  case,  that 
of  a  soldier,  the  superior  ganglion  of  the  right  sympa- 
thetic" was  twice  the  size  of  the  left  and  was  the  seat 
of  hemorrhagic  effusion;  microscopically,  the  nerve- 
fibers  were  seen  to  be  separated  and  disintegrated. 
There  were  small  hemorrhages  in  the  upper  part  of  the 
right  sympathetic,  while  slight  effusions  of  blood  were 
found  in  and  around  both  vagi  and  in  the  sheaths  of 

15.  Wiener  med.   Presse.   1884.   p.    1077. 

16.  Virchow's  Arch..  1873.  bd.  Ivii.  p.   121. 

17.  Berliner  klin.  Woeh..  1875. 'No.  34. 


both  phrenic  nerves.  In  the  second  case,  that  of  a 
woman  21  years  of  age,  the  pathologic  phenomena  were 
a  hemorrhagic  infiltration  and  enlargement  of  both  su- 
perior ganglia  of  the  cervical  sympathetic,  while  the 
microscope  revealed  the  same  appearances  as  in  the  other 
case :  there  were  also  ecchymoses  as  large  as  peas  in  both 
Vagi.  In  the  first  case,  the  patient  had  lived  twenty- 
four  hours,  having  a  pulse  so  rapid  that  its  beats  could 
scarcely  be  counted;  there  was,  however,  no  acceleration 
of  the  respiration. 

GLAUCOMA. 

The  ganglia  excised  in  Ball's  cases  were  examined  by 
Dr.  Carl  Fisch18  of  St.  Louis.  A  great  number  of  dif- 
ferent staining  methods  were  employed,  but  those  of 
Golgi,  March!  and  Xissl  were  not  employed,  on  account 
of  the  method  of  hardening  the  specimen.  The  changes 
found  were  approximately  the  same  in  all  cases. 

The  most  striking  change  Avas  "a  very  marked  hyper- 
plasia  of  the  connective  tissue,  which,  in  some  places, 
resulted  in  dividing  up  the  ganglion  into  small  groups 
of  nervous  elements,  separated  by  broad  bands  of  fibrous 
elements."  There  was  decided  sclerosis  of  the  walls  of 
the  vessels  and  the  capsules  of  the  ganglion  cells  were 
"much  increased  in  thickness."  "In  Case  1,  small  foci 
of  round-cell  infiltration  are  seen  in  this  hyperplastic 
growth  of  an  inflammatory  character."  No  "plasma  or 
mast-cells"  could  be  demonstrated. 

The  ganglion  cells  were  "immensely"  pigmented; 
many  were  in  various  stages  of  degeneration.  Only  a 
few  showed  normal  dendritiform  processes.  The  net- 
work of  processes  was  reduced  in  volume  and  compressed 
by  the  connective  tissue  new  formation.  The  general 
aspect  Avas  that  of  a  general  sclerosis,  inflammatory  and 
originating  in  the  walls  of  the  vascular  structures.  The 
changes  in  the  nerA'ous  elements  are  attributed  to  pres- 
sure and  inhibited  nutrition. 

Ziehe  and  Axenfeld  (Sympatheticus-Resection  beim 
Glaucoma,  Halle,  1901)  report  the  examination  of  fiA-e 
ganglia  removed  from  three  patients  at  Eostock.  The 
ganglia  Avere  examined  by  Dr.  Keeker,  Privatdocent, 
working  in  the  Pathologic  Institute  at  Rostock. 

CASE  1. — Capsule  thick;  the  connective  tissue  that  accom- 
panied the  blood  vessels  was  also  thickened.  Connective  tis- 

18.   Ninth  Internat.  Ophthal.  Congress.   Utrecht.  1899,  p.  554. 


108 

sue  poor  in  nuclei.  Often  the  adventitia  was  thicker  than  the 
remaining  portion  of  the  wall  of  the  vessel,  plus  the  lumen 
of  the  vessel.  A  slight  increase  in  the  small  cells  was  observed 
in  the  vicinity  of  the  vessels.  No  change  in  nerve  elements. 
Both  ganglia  presented  the  same  microscopic  appearance. 

CASE  2. — Right  ganglion;  marked  diffuse  interstitial  scle- 
rosis, most  pronounced  in  the  vicinity  of  the  larger  blood  ves- 
sels. Nerve  elements  normal.  The  left  ganglion  showed  the 
same  changes,  but  to  a  less  degree.  Leucocytes  slightly  in- 
creased in  number. 

CASE  3. — The  left  ganglion,  which  was  the  only  one  re- 
moved, showed  increase  of  the  connective  tissue  about  the 
blood  vessels;  adventitia  very  much  thickened.  Diffuse  in- 
terstitial sclerosis  absent. 

Lodato19  examined  two  ganglia  removed  from  a  pa- 
tient with  glaucoma  and  found  hyperplasia  and  sclerosis 
of  the  connective  tissue  and  a  peripheral  small-cell  in- 
filtration. The  sclerosis  was  more  marked  in  the  gang- 
lion from  the  older  patient,  the  small-cell  infiltration  in 
the  ganglion  from  the  younger  patient. 

In  the  first  he  found  a  number  of  small  hemorrhages 
which  had  destroyed  some  of  the  nervous  elements. 
There  was  some  degeneration  of  a  few  of  the  medullated 
nerve-fibers.  No  change  in  the  nerve-elements  in  the 
second  case. 

Lodato  questions  whether  the  small-cell  infiltration 
might  not  have  produced  an  irritation  which  could  have 
caused  a  hypersecretion  of  fluids  into  the  globe,  and  thus 
have  established  the  first  stage  of  the  glaucoma.  There 
is  no  report  of  control  examinations. 

Albertotti20  gives  an  example  of  ten  superior  cer- 
vical sympathetic  ganglia,  the  cut  being  reproduced 
from  a  photograph,  which  shows  them  to  be  of  various 
sizes  and  shapes. 

Cutler21  reports,  regarding  the  microscopic  examina- 
tion of  one  superior  cervical  ganglion  removed  from  a 
patient  suffering  from  glaucoma  simplex,  as  follows: 

Spofimen  5  centimeters  long,  %  centimeter  in  diameter. 
At  one  point  for  1%  centimeters  is  a  thickening.  Section* 
through  whole  length  of  specimen  show  large  ganglion  cells. 
In  these  cells  the  chromophilic  bodies  do  not  show  the  normal 
size  and  arrangement,  and  many  cells  show  small  granules  of 
pigment.  A  growth  of  connective  tissue  is  between  the  gang 
lion  cells.  Nerve  fibers  are  normal. 

19.  Arch,  di  ottalm,,  vol.  viii,  p.  358. 

20.  Ann.  di  ottalm.,  Naples,  xxix,  p.  472. 

21.  Annals  of  Surgery,  Phila.,  September,  1902. 


109 

When  we  take  into  consideration  the  fact  that  de- 
generative changes  in  the  cervical  sympathetic  occur  in 
the  old,  whether  there  is  marked  evidence  of  disease  or 
not,  it  becomes  apparent  that  it  is  necessary  to  make 
control  examinations  before  we  can  reach  any  reliable 
definite  conclusion  regarding  the  condition  of  the  cer- 
vical sympathetic  in  individuals  suffering  from  glau- 
coma, or,  in  fact,  in  any  disease  supposed  to  be  due  to 
pathologic  changes  in  the  cervical  sympathetic.  Such 
control  experiments  were  made  by  Dr.  Ira  Van  Giesen, 
in  connection  with  the  examination  of  the  ganglia  re- 
moved, in  the  cases  reported  by  the  writer.22  His  report 
follows : 

Seven  ganglia  have  been  examined  microscopically,  includ 
ing  two  bilateral  operations,  comprising  thus  five  different 
cases.  The  work  has  been  paralleled  by  the  examination  of 
control  ganglia  taken  from  subjects  as  near  as  possible  the 
same  age  as  the  operation  cases.  As  the  control  studies  are 
very  important  in  an  examination  of  this  kind,  the  normal 
ganglia  were  subjected  to  precisely  the  same  steps  as  in  the 
operation  cases,  and  carried  along  with  them  side  by,  side. 
Four  ganglia  of  normal  subjects  were  studied  as  controls  and 
secured  in  autopsies  averaging  about  twenty-four  hours  after 
death.  (Thus  far,  however,  but  two  of  the  control  ganglia 
have  been  complete  for  study.) 

We  have  endeavored  to  bring  to  bear  on  the  question  as  com- 
prehensive an  examination  as  possible,  and  the  technic  has 
been  directed  toward  all  of  the  structures  of  the  ganglion  in 
the  following  order:  (1)  The  detection  of  any  cytologic 
changes  in  the  neuron  cell  bodies.  (2)  A  special  study  of 
the  so-called  pigment  granules  in  the  neuron  cell  bodies.  (3) 
An  examination  of  the  connective  tissue  framework  of  the 
ganglion.  (4)  A  study  of  the  blood  vessels;  and  (5)  the  ex- 
amination of  the  medullated  and  non-medullated  fibers. 

Special  methods,  both  of  fixation  and  staining,  have  been 
used  for  each  of  these  points  in  both  sets  of  ganglia — the 
operation  cases  and  the  control  cases — and  in  all  some  three 
hundred  sections  have  been  examined.  Ten  different  fixations 
have  been  employed,  as  well  as  the  several  varieties  of  stain- 
ing methods  best  adapted  for  the  demonstration  of  each  of  the 
objects  of  examination. 

1.  The  Neuron  Cell  Bodies. — Throughout  the  series  of  op- 
erated cases,  the  neuron  cell  bodies  show  the  normal  arrange- 
ment and  distribution  of  the  chromophilic  granules.  There 
are  no  evidences  of  degeneration,  nor  is  there  any  atrophy  or 
signs  of  disappearance  of  the  neuron  cell  bodies.  In  a  very 

22.  Trans.  Amer.  Ophth.  Soc.,  1902,  p.  455. 


110 

few  places,  in  fact,  of  quite  exceptional  occurrence,  there  are 
appearances  which  might  be  considered  as  similar  to  the  form 
of  chromatolysis  in  the  centers  of  the  neuron  cell  bodies  seen 
in  the  central  nervous  system.  This,  however,  is  also  seen 
in  the  control  cases,  and  it  seems  to  be  of  no  significance  ir 
relation  to  the  production  of  the  glaucoma. 

2.  The   Pigment    Granules. — The    capsules    of    the   ganglion 
cells   are   also   without   alteration.     The    pigment   grains    are 
certainly  increased   in  the  glaucoma   cases  as  compared   with 
the  control  cases.     A    larger    number    of    cells    contain   pig- 
ment grains  in  the  glaucoma  cases,  and  the  aggregate  volume 
of  the  pigment  grains  is  greater.     While  the  control  cases  con 
tain  a  considerable  amount  of  pigment  particles,  this  can  be 
reckoned  as  being  only  fifty  to  sixty  per  cent,  of  the  quantity 
in  the  operation  cases. 

3.  The   Connective   Tissue. — Studied   in    specimens   prepared 
in   Fleming's  weak   and  strong  solutions   and   stained  by  the 
picric  acid   fuschin   method,   the  connective  tissue  framework 
shows  no  signs  of  proliferation  or  degeneration  in  the  glau- 
coma cases.     One  would  not  be  able  to  distinguish  between  the 
operation   cases   and   the   controls,   judging  by  the  connective 
tissue. 

4.  The  Blood  Vessels. — These  were   examined  with  especial 
attention,  both  in  the  substance  of  the  ganglion   and   in  the 
loose  connective  tissue  surrounding  it.    The  vessels  are  normal. 

5.  The  Fibers. — The   medullated  fibers   in   the  ganglion   are 
so  relatively  few  as  compared  with  the  non-medullated  fibers 
that  Weigert's  method  of  staining  the  medullated  sheath  leaves 
the   section  quite  decolorized.     There   are   not   enough   medul 
lated  fibers  to  take  the  stain.     Under  the  microscope,  however, 
the  bundles  of  fibers  in  the  ganglion  show  here  and  there  the 
darkly-stained  medullated  fibers  among  the  axons.     Compared 
with  the  controls  there  seems  to  be  no  differences  in  the  non- 
medullated  fibers. 

Summary. — We  find,  then,  that  as  far  as  our  methods  of 
examination  of  hardened  material  go  the  ganglia  seem  to  be 
normal  with  the  exception  of  an  excess  of  pigment  in  the 
neuron  cell  bodies,  and  as  to  the  significance  of  this,  if  it  has 
any,  we  are  entirely  as  yet  in  the  dark.  The  result  of  the 
examination  does  not  positively  preclude  the  existence  of  a 
lesion  in  the  ganglia.  (The  ganglia  were  examined  at  the 
new  pathologic  laboratory  of  the  Women's  Infirmary  of  New 
York.) 

Dr.  W.  H.  Wilder  of  Chicago  has  kindly  permitted  me 
to  refer  to  the  microscopic  findings  in  the  ganglia  re- 
moved from  patients  with  glaucoma  in  his  service.  The 
examinations  were  made  by  Dr.  Sidney  Kuh,  who  re- 
ports as  follows:  Excess  of  pigment  in  the  ganglion 


Ill 

cells  (age  a  factor?)  ;  cells  not  round,  often  appear 
shrunken;  eccentric  nuclei,  occasionally  only  the  nu- 
cleolus  visible ;  cells  at  times  vacuolated ;  mast  cells ;  vas- 
cularity.  All  of  these  findings  were  present  in  each 
case  except  the  second  finding  (that  of  the  cells  not  be- 
ing round),  as  in  some  of  the  specimens  the  cells  were 
perfectly  round. 

Onuf  and  Collins23  write: 

Concerning  the  morbid  findings  in  cases  of  Graves'  disease, 
Moebius  has  recently  written:  "All  sorts  of  conditions  have 
been  described;  the  ganglia  are  too  large  or  too  small;  the 
nerve  too  thick  or  too  thin;  there  is  too  much  connective 
tissue  or  too  few  nerve  cells;  the  nerve  cells  are  deformed, 
shrunken,  or  pigmented;  there  are  small  hemorrhages,  de- 
struction of  nerve  fibers,  etc.,  etc.  To  all  of  which  we  make 
an  affirmative,  choosing  to  disregard  the  writer's  attempt  at 
irony.  We  have  learned  in  recent  years  that  in  individuals 
dying  of  long-standing  nervous  disease,  the  so-called  func- 
tional as  well  as  organic,  there  are  also  invariably,  especially 
if  the  individual  be  somewhat  advanced  in  years,  retrogres- 
sive changes  in  the  nervous  system.  Although  Moebius  comes 
to  the  conclusion  that  in  the  majority  of  cases  of  Graves' 
disease  nothing  characteristic  or  essential  is  to  be  found  in 
the  cervical  sympathetic  to  explain  the  pathogenesis  of  the 
disease,  it  does  not  seem  to  us  that  investigation  of  the 
vegetative  system  of  nerves  in  its  peripheral  and  central 
distribution  has  been  sufficiently  comprehensive  to  give  tena- 
ability  to  his  position." 

The  following  report  is  from  the  examination  of  nine 
ganglia  removed  from  patients  suffering  from  exoph- 
thalmic goiter.  Five  of  these  patients  were  in  the  prac- 
tice of  Dr.  B.  Farquhar  Curtis,  who  has  kindly  per- 
mitted me  to  make  use  of  the  report.  The  examinations 
were  made  by  Dr.  F.  C.  Wood,  pathologist  to  St.  Luke's 
Hospital,  to  whom  I  am  indebted.  I  wish  to  express 
my  thanks  to  both  these  gentlemen  for  their  courtesy. 
This  report  is  of  practical  value  because  of  the  control 
examinations,  which  were  made  in  connection  with  the 
examination  of  the  ganglia  removed  from  patients  suf- 
fering from  exophthalmic  goiter. 

1.  There  is  no  definite  increase  in  the  connective  tissue  of 
the  ganglia. 

2.  Pigmentation  of  the  ganglion  cells  is  quite  constant  and 
abundant,  though  not  present  in  all  cells. 

23.  B.  Onuf  and  Joseph  Collins :  "Experimental  Researches  on 
the  Cervical  Sympathetic,"  etc.,  Archives  of  Neurology  and  Psycho- 
pathology,  vol.  iii,  Nos.  1  and  2,  p.  217. 


112 

3.  A  small  proportion,  always  less  than  half,  of  the  gang- 
lion   cells    shows    a    central    chromatolysis    when    stained    by 
Nissl's  method.     In  some  cells  the  change  was  advanced  and 
no  chomophilic  bodies  could  be  seen;  in  others  they  were  clus- 
tered about  the  periphery  of  the  cell.     The  nuclei  were  often 
eccentric  in  the  degenerated  cells. 

4.  No   fiber  degeneration  could   be  demonstrated.     All   the 
ganglia  showed  about  the  same  changes. 

Control  ganglia  from  autopsy  cases  dying  from  a  variety 
of  diseases  did  not  show  marked  chron*atolysis,  though  an 
occasional  cell  with  degeneration  could  be  seen.  The  amount 
of  pigment  formed  was  variable  in  these  controls.  It  was 
more  abundant  in  the  aged  than  in  adults,  but  a  certain 
amount  seems  to  be  present  in  some  of  the  ganglion  cells  of 
the  sympathetic,  at  least  in  cases  which  I  have  been  able 
to  examine. 

Keports  of  changes  in  the  cervical  sympathetic  ob- 
served in  different  pathologic  conditions  affecting  the 
system  locally  and  generally,  make  it  evident  that  as 
yet  no  change  has  been  found  that  is  peculiar  to  glau- 
coma. The  findings  in  the  cases  of  Ball,  Ziehe  and 
Axenfeld,  Lodato  and  Cutler,  are  uniform  in  regard  to 
the  hyperplasia  of  connective  tissue.  This  was  also  found 
by  Petrow  in  cases  of  constitutional  syphilis,  and  by 
Pio  Foa  in  patients  with  various  diseases.  Slight  in- 
filtration of  small  cells  does  not  appear  to  be  peculiar 
to  glaucoma. 

Changes  in  the  nervous  elements  are  reported  by  Ball, 
by  Cutler  and  by  Kuh.  These  were  not  observed  by 
Ziehe  and  Axenfeld,  nor  by  Lodato,  except  in  the  presence 
of  pigment  granules.  Changes  in  the  ganglion  cells  were 
observed  by  Petrow  in  individuals  suffering  from  con- 
stitutional syphilis.  The  validity  of  the  statements  re- 
garding the  uniform  increase  of  connective  tissue  is 
somewhat  shaken  by  the  results  of  Van  Giesen's  ex- 
aminations, as  no  such  increase  could  be  demonstrated 
in  the  seven  ganglia  which  he  examined.  Kuh  also  fails 
to  irtention  an  increase  of  connective  tissue. 

The  testimony  in  our  possession  is  not  sufficiently 
conclusive  to  enable  us  to  say  that  there  is  any  constant 
change  in  the  cervical  sympathetic  peculiar  to  glaucoma. 
Nor  is  it  sufficiently  conclusive  to  exclude  the  possi- 
bility of  such  constant  change.  Farther  and  more  care- 
ful research  is  necessary;  first,  probably  along  the  lines, 
suggested  by  Dr.  Van  G-iesen,  viz.,  by  means  of  the  Ehr- 
lich  methylene  blue  method  with  fresh  ganglia  or  by 


113 

other  equally  delicate  methods  for  the  purpose  of  de- 
termining the  conditions  of  the  processes  of  the  neu- 
rons and  the  cell  structure,  and,  second,  a  study  of  the 
pigmentation  of  the  neurons,  which  must  be  made  in 
comparison  with  control  studies. 

DISCUSSION 

ON  THE  PAPERS  OF  DUS.  DE  SCHWEINITZ,  WILDER,  BALL  AND 
WEEKS, 

DR.  MELVILLE  BLACK,  Denver — It  has  been  a  great  privilege 
to  listen  to  these  papers,  and  I  am  sure  we  must  all  feel  that 
we  know  more  about  the  subject  now  than  we  did  before.  It 
is  a  particularly  interesting  subject  to  me,  and  I  believe  that 
we  can  feel  from  the  statistics  presented  so  far  that  the  opera- 
tion is  one  of  value.  It  is  an  operation,  however,  that  is  to 
be  properly  considered.  My  own  personal  feelings  are  that  it 
should  not  be  performed  as  a  last  resort,  but  really  as  a  first 
one.  The  statistics  of  the  operation  will  be  vitiated,  and  have 
been  up  to  the  present  time,  by  attempting  it  as  a  procedure 
where  nothing  could  possibly  be  of  any  benefit.  If  sympathec- 
tomy  is  to  be  of  any  service  it  must  be  before  the  filtration 
angle  is  blocked  or  closed.  If  this  angle  has  been  occluded  it 
is  a  question  if  the  operation  can  be  of  any  permanent  benefit. 
It  would  seem  to  me  that  where  eserin  has  a  prompt  action  in 
relieving  tension  and  pain  and  in  improving  vision  and  bring- 
ing up  the  field,  that  the  action  of  sympathectomy  should  be 
correspondingly  good  and  more  permanent;  that  is,  we  can 
liken  somewhat  the  after-effects  of  sympathectomy  to  the 
effects  we  obtain  from  the  use  of  eserin.  Of  course,  we  can  not 
continue  the  use  of  eserin  indefinitely,  and  if  we  have  in  this 
procedure  something  permanent,  it  is  certainly  of  great  value. 

I  am  inclined  to  believe  that  the  results  will  not  be  as 
permanent  as  we  would  wish.  With  watching  this  one  case 
of  mine  it  has  seemed  to  me  that  the  eye  is  getting  from  some 
source  more  and  more  sympathetic  nerve  power.  The  ptosis 
is  subsiding;  the  eye  is  no  longer  congested;  the  pupil  is  be- 
coming more  nearly  the  size  of  its  fellow;  at  one  time  we  had 
.50  diopter  of  myopia — we  now  have  .50  diopter  of  hyper- 
metropia.  Therefore  it  would  seem  to  me  that  this  eye  is 
gradually  regaining  its  sympathetic  nerve  supply. 

It  would  seem  to  me  that  where  this  operation  is  done  a 
sufficiently  extensive  procedure  should  be  adopted  to  insure 
as  much  cutting  off  as  possible  of  the  sympathetic  nerve 
supply;  and  that  therefore  it  would  seem  well  to  excise  the 
middle  ganglion  with  the  superior.  Any  one  who  has  watched 
the  operation  will  have  noticed  how  associated  these  two 
ganglia  are  and  how  easy  it  would  be  in  removing  the 
superior  alone  to  have  a  supply  from  the  middle.  Dr.  Free- 
8 


114 

man,  Denver,  has  operated  on  ten  cases,  removing  both  gan- 
glia. Only  one  of  these  operations,  however,  was  done  for  glau- 
coma. He  has  seen  in  his  practice  no  undesirable  results 
following  this  procedure,  and  his  opinion  was,  as  I  obtained  it, 
that  the  operation  was  a  comparatively  easy  one  unless  the 
subject  were  an  enormous,  bull-necked  individual.  The  scar 
resulting  is  slight,  provided  a  buried  suture  is  placed,  and  in 
the  course  of  three  or  four  months  it  is  scarcely  possible  to 
find  a  scar.  The  only  thing  of  serious  consequence  that  may 
follow  is.  neuralgia,  and  that  seems  to  be  due  to  rather  un- 
necessary bruising  of  some  of  the  nerves  that  come  off  through 
the  vertebrae. 

I  think  that  this  operation  is  one  that  we  should  all  con- 
sider, so  far  as  our  statistical  results  present,  as  being  one 
of  value,  and  while  we  should  not  embrace  it  with  too  much 
enthusiasm,  yet  at  the  same  time  we  should  give  it  the  benefit 
of  the  doubt  as  being  of  some  service,  and  we  should  not  depend 
on  the  operation  only  where  iridectomy  has  failed  and  all  other 
known  procedures  have  failed.  It  should  be  tried  first,  not  last. 
Several  cases  have  been  reported  where  the  operation  has  been 
of  value  even  after  iridectomy  has  failed.  This  might  lead 
us  to  think  that  in  certain  cases  ganglion  excitation  existed 
and  that  the  removal  of  the  ganglia  relieved  that  irritation, 
which  might  have  been  the  beginning  cause  of  the  glaucoma. 

DR.  G.  C.  SAVAGE,  Nashville,  Tenn. — I  believe  we  have  some 
reasons  for  holding  the  opinion  that  the  sympathetic  nervous 
system  is  the  source  of  power  that  Nature  has  given  us  for 
the  correction  of  astigmatism.  That  in  early  life  every  astig- 
matic eye  has  the  power  of  correcting  a  considerable  portion  of 
its  defect,  if  not  all,  is  now  universally  believed.  One  must 
certainly  be  convinced  that  Nature  has  furnished  some  power 
by  which  this  defect  is  remedied.  It  is  not  in  Mueller's  muscle, 
nor  in  the  third  nerve.  In  my  own  case  atropin  and  homa- 
tropin  were  used  to  uncover  my  error  of  refraction,  but  both 
failed.  I  am  to-day  wearing  a  lens  four  times  as  strong  as 
that  with  which  I  commenced.  Each  time  the  increase  was 
made  I  got  additional  relief,  until  finally  the  full  strength  lens 
was  given.  I  happened  to  be  in  Dr.  Burnett's  office  in  1889 
and  my  corneal  astigmatism  was  the  same  then  as  it  is  to-day. 
A  coasiderable  portion  of  my  astigmatism  was  corrected  by 
some  means  within  the  eye  in  spite  of  a  mydriatic. 

Only  two  meridians  of  any  cornea  that  is  astigmatic  have  a 
focus — the  two  principal  meridians.  One  is  the  meridian  of 
greatest  curvature,  and  the  other  of  least  curvature.  When 
Mueller's  muscle,  supplied  by  the  third  nerve,  contracts,  the 
lens  is  made  more  convex,  and  the  two  foci  are  brought  into 
definite  relation  with  the  retina,  but  not  closer  to  each  other, 
hence  they  are  not  made  to  fuse.  The  other  muscle  in  the 
ciliary  body  is  that  of  Bowman,  which  I  believe  is  controlled 


115 

by  the  superior  cervical  sympathetic.  If  under  the  influence 
of  the  sympathetic  some  fibers  of  Bowman's  muscle  can  be 
thrown  into  contraction  while  others  are  not,  it  would  result 
in  tilting  of  the  lens.  When  the  lens  is  tilted  on  an  axis  in 
the  plane  of  the  meridian  of  greatest  curvature  the  two  foci 
are  made  to  approach  each  other,  and  if  the  tilting  be  far 
enough  they  are  fused  into  one.  The  power  given  vis  by  Nature 
for  the  correction  of  astigmatism  is  in  Bowman's  muscle,  and 
I  believe  it  acts  under  the  influence  of  the  superior  cervical 
sympathetic  ganglion. 

UK.  GEOHGE  F.  SUKER,  Chicago — I  maintain  that  the  relation 
between  any  form  of  glaucoma  and  the  sympathetic  nervous 
system,  including  the  cervical,  is  still  open  for  considerable 
debate.  We  do  not  to  a  certainty  know  the  physiologic  tracts 
of  the  cranial  sympathetic  fibers  in  all  instances;  nor  do  we 
know  whether  or  not  these  sympathetic  fibers  decussate  in  all 
individuals  as  do  the  cranial  nerves  proper.  The  ganglion  of 
Ribes,  situated  on  the  anterior  communicating  artery,  is  not 
present  in  every  instance  according  to  some  anatomists.  Yet, 
if  it  is  present,  it  is  here  where  the  cephalic  extremities  of  the 
ascending  branches  of  the  cervical  sympathetic  fibers  join  and 
cross.  This  point  may  explain  why,  in  some  cases,  a  unilateral 
excision  of  the  ganglion  is  of  only  temporary  benefit.  For,  if 
this  communication  does  exist,  it  is  not  unreasonable  to  sup- 
pose that  the  opposite  side  is  furnishing  the  abnormal  stim- 
ulus through  the  intact  cephalic  ends  of  the  excised  side. 
Just  as  the  other  corresponding  nerve  centers  take  up  the 
function  of  its  fellow  when  it  is  destroyed,  so  may  the  sym- 
pathetic system,  by  means  of  its  ganglia,  do  the  same.  This 
fact  may  and  does  explain  why  in  Dr.  Black's  case  there  was 
a  return  of  the  function  of  the  sympathetic  with  its  detri- 
mental effects  on  the  side  operated  on. 

There  is  no  justification  in  excising  the  middle  cervical 
ganglion  as  well  as  the  superior  for  glaucoma.  However,  it 
is  very  necessary  to  cut  the  connecting  cord  and  excise  that 
ascending  branch  of  the  middle  ganglion  which  connects  with 
the  ascending  fibers  of  the  superior  ganglion  high  up  in  the 
neck.  It  is  only  the  cavernous  and  carotid  plexuses  of  the 
superior  ganglion  which  hav.e  any  relation  to  the  eye.  For 
reasons  already  stated  it  is  necessary  to  completely  destroy 
the  connections  between  these  two  ganglia. 

The  ciliary  or  lenticular  ganglion  must  also  be  considered 
if  we  expect  to  explain  the  relation  of  the  sympathetic  fibers 
to  glaucoma.  For,  it  is  the  upper  two-thirds  which  contain 
sympathetic  filaments  supplying  the  anterior  segment  of  the 
eye.  The  lower  third  of  this  ganglion  receives  a  branch  of  the 
third  nerve.  Furthermore,  the  sympathetic  fibers  in  the  rami 
communicantes,  which  are  closely  associated  with  the  fifth 
nerve  and  enter  the  eye  along  with  the  optic  nerve,  must  be 


116 

seriously  considered.  These  branches  also  supply  the  segment 
of  the  eye  around  which  centers  the  pathology  of  glaucoma. 
The  experiments  of  Anderson,1  Delens-  and  Rohmer3  with  the 
sympathetic  supply  of  the  eye  are  to  be  considered  in  solving 
its  relation  to  glaucoma.  Especially  are  these  various  sym- 
pathetic fibers  and  ganglia  to  be  surgically  thought  of  in  glau- 
coma, for  we  know  that  the  superior  cervical  is  frequently,  if 
not  invariably,  histologically  changed.  What  is  true  for  this 
ganglion  may  hold  true  for  the  others  also. 

In  no  case  of  glaucoma  have  all  the  sympathetic  fibers  and 
ganglia,  on  one  or  both  sides,  supplying  that  eye  ever  been 
severed.  Experimentally  they  have,  then  tension  was  reduced 
and  the  iris  remained  contracted,  both  permanently. 

It  is  questionable,  as  Dr.  de  Schweinitz  has  stated,  whether 
any  trophic  actions  can  be  ascribed  to  the  sympathetic  nerves. 
As  yet  we  are  not  in  a  position  to  attribute  any  trophic  func- 
tions to  certain  kind  of  nerves.  The  untoward  effects  which 
follow  the  extirpation  of  the  superior  sympathetic  ganglion 
are  trivial  and  not  permanent.  The  only  one  to  receive  any 
consideration  is  the  enophthalmus;  this,  however,  is  only 
slight  and  does  not  supervene  in  every  case. 

The  statistics  here  given  by  Drs.  Wilder  and  Ball  show  that 
the  operation  was  undertaken  in  such  cases  as  might  well  be 
called  desperate.  Therefore,  the  operation  has  not  been 
awarded  a  fair  trial.  There  is  no  doubt  that  in  well- 
selected  cases  it  will  accomplish  what  an  iridectomy  will  not. 
In  my  hands  the  operation  has  been  successful  in  a  few  in- 
stances, as  the  reports  of  the  cases  show.  What  good  the  ex- 
cision of  the  ganglion  will  do  in  optic  atrophy  is  yet  de- 
batable. In  the  case  on  which  I  operated  I  did  obtain  a  de- 
cided benefit,  though  temporary.  Dana  of  New  York  tried  it 
in  a  case  of  tabetic  atrophy,  though  with  what  success  I  could 
not  ascertain. 

Several  years  ago  I  was  quite  enthusiastic  concerning  the 
future  of  sympathectomy;  but  of  late  I  have  become  very 
conservative,  as  my  paper  before  this  Section  in  1901  clearly 
demonstrated. 

DR.  EDWARD  JACKSON,  Denver — The  trend  of  the  papers 
would  seem  to  indicate  that  we  are  not  in  a  position  to  decide 
man> . questions  in  reference  to  the  use  of  excision  of  the 
sympathetic  ganglia  in  glaucoma.  Yet  in  going  over  the 
literature  one  point  seemed  pretty  clear  to  me,  and  that  is 
confirmed  this  morning.  Dr.  Black  broached  it  when  he  said 
that  the  case  in  which  excision  does  good  is  the  case  favorably 
influenced  by  eserin.  I  think  there  is  enough  evidence  now, 
although  it  lies  in  a  very  small  minority  of  the  published 

l.i  Jour.    Phys..   vol.   xxviii.   No.    3. 

2.  Bull,  de  la  Soc.  de  Chlrnrgle.  April,  1902, 

3.  Annals   d'OcuUstlque,   July,  1902. 


117 

cases,  to  indicate  that  sympathectomy,  or  excision  of  the 
ganglia,  will  do  good  in  the  cases  that  would  be  benefited  by 
iridectomy.  If  we  consider  apart  those  cases  in  which  iridec- 
tomy  would  have  been  a  hopeful  operation,  I  think  the  record 
for  sympathetic  excision  is  very  promising.  That  might  ap- 
pear to  be  saying  that  operations  on  the  sympathetic  had  no 
place  where  iridectomy  is  an  established  operation,  but  such 
is  not  the  case.  I  think  sympathectomy  may  be  of  value  in 
an  important  class  of  cases ;  as  where  one  eye  has  been  lost  and 
it  is  difficult  to  get  the  patient  to  consent  to  an  operation  on 
the  other  eye  at  the  stage  where  the  operation  is  most  hopeful, 
where  iridectomy  can  not  be  done,  or  the  patient  can  not  be 
induced  to  have  it  done,  and  yet  where  if  it  were  done  the 
probabilities  would  be  in  favor  of  it,  we  are  now  justified  in 
urging  operation  on  the  sympathetic.  The  cases  where  iridec- 
tomy is  reported  to  have  been  done  and  no  good  accom- 
plished, and  then  sympathectomy  has  been  efficient,  might  seem 
to  lead  in  another  direction.  I  have  seen  one  case  where  iridec- 
tomy did  no  good  and  sympathectomy  afterwards  restored 
vision.  But  it  may  be  that  in  some  of  these  cases  where 
iridectomy  is  said  to  have  been  done  it  has  not  been  a  broad, 
complete  excision  of  the  iris,  which  I  believe  necessary  to  give 
iridectomy  its  best  effect. 

DR.  G.  E.  DE  SCHWEINITZ,  Philadelphia — The  members  of  the 
Section  must  have  realized  that  it  has  been  impossible  in  pre- 
senting a  resume  of  the  physiologic  side  of  this  question  to 
read  in  detail  the  experiments  and  observations  on  which  the 
conclusions  were  based.  For  example,  I  did  not  have  time  to 
discuss  the  question  of  the  pupil-dilating  fibers  which  do  not 
run  in  the  sympathetic  system,  although  in  the  extended  paper 
I  have  made  reference  to  them.  I  confess  that  I  am  distinctly 
skeptical  as  to  the  permanent  value  of  sympathectomy  in  the 
treatment  of  glaucoma,  although  I  realize  that  a  certain  num- 
ber of  brilliant  results  have  followed  this  operation,  and  also 
realize  that  at  present  our  statistical  information  is  to  a  cer- 
tain extent  misleading,  because  the  operation  has  in  most  in- 
stances been  utilized  as  a  last  resource,  and  therefore  the  re- 
sults of  prompt  interference  according  to  this  method  are  not 
at  our  disposal,  or,  at  least,  at  our  disposal  in  a  most  limited 
degree.  Dr.  Black's  idea  that  if  the  effect  of  eserin  on  a 
glaucomatous  eye  is  good,  we  may  reason  that  sympathectomy 
would  likewise  be  followed  by  good  results,  does  not  seem  to 
me  to  be  an  entirely  safe  guiding  principle.  Eserin  accom- 
plishes its  good  in  those  cases  in  which  it  is  able  to  release  the 
filtration  angle  from  blockade  by  contracting  the  pupil  and 
drawing  the  periphery  of  the  iris  away  from  the  danger  of 
adhesive  inflammation  to  the  structures  in  the  filtration  angle. 
Now,  in  a  certain  number  of  cases,  perhaps  in  the  majority  of 
cases  in  which  sympathectomy  has  been  performed,  the  process 


118 

has  been  a  chronic  one  in  which  pronounced  blockade  in  the 
filtration  angle  was  lacking,  cases  in  which  it  is  possible  that 
there  may  have  been  a  hypersecretion  of  the  intra-ocular 
fluids,  or  an  increased  serosity.  Cases  of  acute  glaucoma  are 
just  the  ones  in  which  strong  solutions  of  the  myotics  give 
frequently  the  best  temporary  relief,  and  they  are  certainly 
not  the  ones  in  which  the  sympathectomy  is  advisable,  at  least, 
as  far  as  our  present  knowledge  goes.  I  entirely  agree  with 
Dr.  Suker,  and  all  physiologic  investigation  is  on  his  side, 
that  it  is  not  necessary  to  excise  the  middle  ganglion.  Ex- 
cision of  the  superior  ganglion,  which  is  the  relay  station  for 
the  sympathetic  nerve  supply  for  the  whole  of  the  head,  ac- 
complishes everything  that  can  be  accomplished  by  this  opera- 
tion in  so  far  as  the  relief  of  glaucoma  is  concerned.  EC 
ferring  to  Dr.  Savage's  interesting  observations  on  his  own 
eyes,  I  may  say  that  in  the  extended  paper  I  have  reviewed 
at  some  length  the  action  of  the  sympathetic  on  the  eye  in  its 
relation  to  accommodation  and  refraction.  The  evidence  is 
exceedingly  contradictory,  and  the  whole  subject  is  an  invit- 
ing one  for  further  research. 

DR.  WM.  H.  WILDER,  Chicago — The  report  of  the  histologic 
appearance  of  the  ganglia  that  were  excised  was  not  read,  but 
if  any  of  you  are  interested  in  seeing  the  specimens  they  are 
on  exhibition  in  the  next  room.  The  ganglia  do  not  show,  as 
was  stated  by  Dr.  Weeks,  any  increase  in  connective  tissue, 
but  one  can  see  in  the  specimens  that  there  is  an  increase  in 
the  adventitia  of  the  coats  of  the  vessels  and  that  there  is  con- 
siderable pigment  in  the  cells. 

One  important  question  comes  up  in  connection  with  the 
statement  made  by  Dr.  Black,  that  he  considers  that  where 
there  is  good  contraction  of  the  pupil  with  eserin  sympathec- 
tomy would  be  indicated;  one  case  I  have  reported,  Case  7, 
makes  me  doubt  seriously  whether  we  should  resort  to  sym- 
pathectomy or  to  iridectomy  first  in  these  cases  of  simple 
glaucoma,  I  am  skeptical  about  the  value  of  iridectomy  in  true 
simple  glaucoma,  particularly  where  the  anterior  chamber  is  of 
normal  depth,  and  it  is  in  such  cases  that  sympathectomy 
should  do  good.  We  can  not  place  much  reliance  on  either 
procedure,  but  perhaps  we  can  rely  as  much  on  sympathectomy 
as  on*  iridectomy.  The  unpleasant  experience  in  Case  7  sug- 
gests that  possibly  it  might  be  safer  to  do  the  iridectomy  first. 
In  spite  of  the  sympathectomy  in  this  case,  the  tension  and 
the  central  vision  remained  the  same;  the  peripheral  vision 
continued  to  contract  until  it  was  as  though  the  patient  were 
looking  through  a  narrow  gun  barrel.  I  did  an  iridectomy 
and  there  was  hemorrhage  from  the  choroid  and  the  eye  was 
lost.  A  similar  case  has  been  reported  by  Mohr.  However,  in 
such  a  case  the  same  accident  might  happen  if  sympathectoiny 
had  not  been  done. 


119 

It  is  not  fair  to  condemn  the  operation  when  it  fails  to 
restore  an  eye  that  has  atrophy  of  the  optic  nerve,  or  when  it 
fails  to  relieve  pain  in  an  eye  lost  from  glaucoma.  It  should 
be  given  an  early  trial.  The  statistics  indicate  that  the  simple 
chronic  form  is  the  most  suited  for  the  operation,  with  the 
hemorrhagic  form  next. 

DR.  J.  M.  BALL,  St.  Louis — As  to  the  pathologic  changes 
found  in  the  ganglia,  we  have  found  in  exophthalmic  goiter 
that  the  same  pathologic  condition  exists.  It  is"  the  same  in 
each  of  these  conditions — an  overgrowth  of  connective  tissue, 
a  separation  of  the  nerve  elements  and  the  presence  of  pig- 
ment. I  have  been  told  by  Dr.  Fish  of  St.  Louis  that  the 
same  changes  are  found  in  multiple  sclerosis  and  in  tabes. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


OCT  4     1961 
OCT  4    REC0 


Form  L9-50w-ll,'50  (2554)444 


lc\ 


UC  SOUTHERN  REGIONAL  LIBRARY  FAauTY 


A     000414469     7 


